Provider Demographics
NPI:1396459053
Name:ROBERTS, JENNIFER R (PHD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4479 N SUMMER VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-5947
Mailing Address - Country:US
Mailing Address - Phone:434-249-5104
Mailing Address - Fax:
Practice Address - Street 1:2940 W MAPLE LOOP DR STE 303E
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-6036
Practice Address - Country:US
Practice Address - Phone:801-641-1798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-09
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0700X
UT13011824-2501103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical