Provider Demographics
NPI:1548831159
Name:ROTH, JACLYN (LPN)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 AUERBACH PL
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1596
Mailing Address - Country:US
Mailing Address - Phone:618-288-3700
Mailing Address - Fax:
Practice Address - Street 1:121 STEVEN DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:IL
Practice Address - Zip Code:62294-1866
Practice Address - Country:US
Practice Address - Phone:618-288-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043119533164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse