Healthcare Provider Details

I. General information

NPI: 1326975798
Provider Name (Legal Business Name): JORDANA GABRIELLE ROTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12401 ORANGE DR STE 224
DAVIE FL
33330-4343
US

IV. Provider business mailing address

12401 ORANGE DR STE 224
DAVIE FL
33330-4343
US

V. Phone/Fax

Practice location:
  • Phone: 954-385-4696
  • Fax:
Mailing address:
  • Phone: 954-385-4696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY12872
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: