Provider Demographics
NPI:1316321813
Name:ROBERTS, JENNIFER J (LMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:685 S WALL ST
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2831
Mailing Address - Country:US
Mailing Address - Phone:541-633-9581
Mailing Address - Fax:
Practice Address - Street 1:1270 SW CRESTVIEW RD
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-2665
Practice Address - Country:US
Practice Address - Phone:541-633-9581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16122225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist