Provider Demographics
NPI:1366073041
Name:ROBERSON, COURTNEY WHITE (NP)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:WHITE
Last Name:ROBERSON
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 1:160 W. UNIVERSITY PKWY, SUITE C
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305
Mailing Address - Country:US
Mailing Address - Phone:731-286-1510
Mailing Address - Fax:731-286-1510
Practice Address - Street 1:1575 PARR AVE, SUITE B
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024
Practice Address - Country:US
Practice Address - Phone:731-286-1510
Practice Address - Fax:731-286-1510
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27094363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner