=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801838214
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J.B. ROTH AND ASSOC. P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2006
-----------------------------------------------------
Last Update Date | 12/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2110 PRIEST BRIDGE DR STE 4
-----------------------------------------------------
City | CROFTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21114-2472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-584-3808
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 KENT OAKS MEWS
-----------------------------------------------------
City | GAITHERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20878-5672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-687-0857
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JACOB B. ROTH
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 240-687-0857
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------