Healthcare Provider Details

I. General information

NPI: 1689211898
Provider Name (Legal Business Name): JESSICA LYNN ROTHGEB LPN.168683.MEDS-IV
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2019
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 SENECA ST
SANDUSKY OH
44870-3059
US

IV. Provider business mailing address

1510 SENECA ST
SANDUSKY OH
44870-3059
US

V. Phone/Fax

Practice location:
  • Phone: 419-239-4676
  • Fax:
Mailing address:
  • Phone: 419-239-4676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberLPN.168683.MED-IV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: