Provider Demographics
NPI:1902495468
Name:ROTH, JENNIFER L (FNP-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:ROTH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:MATYSKELA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1700 TUTTLE ST
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-3319
Mailing Address - Country:US
Mailing Address - Phone:608-355-3800
Mailing Address - Fax:608-355-7001
Practice Address - Street 1:1700 TUTTLE ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-3319
Practice Address - Country:US
Practice Address - Phone:608-355-3800
Practice Address - Fax:608-355-7001
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11004-33363L00000X
AZ248734207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1902495468Medicaid