Provider Demographics
NPI:1366561870
Name:ROETHLISBERGER, JACQUELINE L (NP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:L
Last Name:ROETHLISBERGER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1310
Mailing Address - Fax:937-522-8068
Practice Address - Street 1:3700 SOUTHERN BLVD STE 201
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1265
Practice Address - Country:US
Practice Address - Phone:855-500-2873
Practice Address - Fax:937-281-3992
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN 199132 COA363LA2200X
OHCOA 03334 NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2731806Medicaid
OH2731806Medicaid