Provider Demographics
NPI:1679977185
Name:ROTH, JENNIFER M (CRNP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:M
Last Name:ROTH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 ORLEANS ST
Mailing Address - Street 2:BLOOMBERG 7308
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287-2101
Mailing Address - Country:US
Mailing Address - Phone:410-955-2914
Mailing Address - Fax:
Practice Address - Street 1:1800 ORLEANS ST
Practice Address - Street 2:BLOOMBERG 7308
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-2101
Practice Address - Country:US
Practice Address - Phone:410-955-2914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR150450363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics