Provider Demographics
NPI:1699862219
Name:ROTH, JEFFREY D (LMSW)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:D
Last Name:ROTH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 CLOVER LANE
Mailing Address - Street 2:
Mailing Address - City:HESSTON
Mailing Address - State:KS
Mailing Address - Zip Code:67062
Mailing Address - Country:US
Mailing Address - Phone:316-650-8035
Mailing Address - Fax:620-667-4757
Practice Address - Street 1:333 N WASHINGTON
Practice Address - Street 2:STE 260
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67501
Practice Address - Country:US
Practice Address - Phone:620-662-4700
Practice Address - Fax:620-622-4757
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLMSW64831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
003764Medicare ID - Type Unspecified