Healthcare Provider Details

I. General information

NPI: 1023258258
Provider Name (Legal Business Name): JENNA ROTACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2009
Last Update Date: 08/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2773 ALDER ST
EUGENE OR
97405-4141
US

IV. Provider business mailing address

2773 ALDER ST
EUGENE OR
97405-4141
US

V. Phone/Fax

Practice location:
  • Phone: 315-292-4367
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: