Healthcare Provider Details

I. General information

NPI: 1891045076
Provider Name (Legal Business Name): JACLYN MARIE ROTH MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACKIE ROTH

II. Dates (important events)

Enumeration Date: 09/14/2012
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2790 CLAY EDWARDS DR STE 600
NORTH KANSAS CITY MO
64116-3274
US

IV. Provider business mailing address

2790 CLAY EDWARDS DR STE 600
NORTH KANSAS CITY MO
64116-3274
US

V. Phone/Fax

Practice location:
  • Phone: 816-691-5048
  • Fax: 816-346-7039
Mailing address:
  • Phone: 816-691-5048
  • Fax: 816-346-7039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1048325
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2011016811
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: