MEDICARE: JACQUELINE MARIE ROTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SC61633275	WA

General Provider Information

NPI Number	:	1669021952
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE MARIE ROTH

Provider Business Mailing Address
First Line	:	5700 172ND ST NE
Second Line	:
City	:	ARLINGTON
State	:	WA
Zip	:	98223-7742
Country	:	US
Telephone Number	:	360-652-9640
Fax Number	:

Provider Business Practice Location Address
First Line	:	5700 172ND ST NE
Second Line	:
City	:	ARLINGTON
State	:	WA
Zip	:	98223-7742
Country	:	US
Telephone Number	:	360-652-9640
Fax Number	:	360-652-2093

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2019
Last Update Date	:	04/06/2026

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Directions to “ JACQUELINE MARIE ROTH ” Practice Location

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