Provider Demographics
NPI:1285409847
Name:ROTHGABER, JESSE P (MED)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:P
Last Name:ROTHGABER
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 YORK RD UNIT 1
Mailing Address - Street 2:
Mailing Address - City:HOLICONG
Mailing Address - State:PA
Mailing Address - Zip Code:18928-5000
Mailing Address - Country:US
Mailing Address - Phone:267-217-3917
Mailing Address - Fax:
Practice Address - Street 1:4950 YORK RD
Practice Address - Street 2:
Practice Address - City:HOLICONG
Practice Address - State:PA
Practice Address - Zip Code:18928-5038
Practice Address - Country:US
Practice Address - Phone:267-227-0277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1643231101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Single Specialty