Provider Demographics
NPI:1104453364
Name:ROBERTSON, JERICA KRISTIN NICOLE (DO)
Entity type:Individual
Prefix:
First Name:JERICA
Middle Name:KRISTIN NICOLE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11606 CHAPMAN HWY STE 2
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:TN
Mailing Address - Zip Code:37865-5270
Mailing Address - Country:US
Mailing Address - Phone:865-609-6980
Mailing Address - Fax:865-609-6982
Practice Address - Street 1:11606 CHAPMAN HWY STE 2
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:TN
Practice Address - Zip Code:37865-5270
Practice Address - Country:US
Practice Address - Phone:865-609-6980
Practice Address - Fax:865-609-6982
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000005417207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine