Provider Demographics
NPI:1801015052
Name:ROTHMAN, JACQUELYN (LCSW)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:ROTHMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JAXI
Other - Middle Name:
Other - Last Name:ROTHMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:130 BUFFALO RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-1159
Mailing Address - Country:US
Mailing Address - Phone:570-524-5294
Mailing Address - Fax:570-577-1957
Practice Address - Street 1:130 BUFFALO RD
Practice Address - Street 2:SUITE 204
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-1159
Practice Address - Country:US
Practice Address - Phone:570-524-5294
Practice Address - Fax:570-577-1957
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0156641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical