Provider Demographics
NPI:1306275664
Name:ROBERTSON, JACQUENITA MARIE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JACQUENITA
Middle Name:MARIE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6130 NEWTON DR
Mailing Address - Street 2:APT 4309
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-5302
Mailing Address - Country:US
Mailing Address - Phone:254-368-3322
Mailing Address - Fax:
Practice Address - Street 1:6130 NEWTON DR
Practice Address - Street 2:APT 4309
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-5302
Practice Address - Country:US
Practice Address - Phone:254-368-3322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX54002183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist