Provider Demographics
NPI:1063923597
Name:ROBERTS, JARED
Entity type:Individual
Prefix:DR
First Name:JARED
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 W SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-4619
Mailing Address - Country:US
Mailing Address - Phone:208-529-5777
Mailing Address - Fax:
Practice Address - Street 1:550 W SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-4619
Practice Address - Country:US
Practice Address - Phone:208-529-5777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-6667101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional