=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366565913
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN ROTH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2007
-----------------------------------------------------
Last Update Date | 09/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 122 W COURT ST
-----------------------------------------------------
City | ITHACA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-275-5965
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6632
-----------------------------------------------------
City | ITHACA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14851-6632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-564-5117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 86401
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 005266
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------