Provider Demographics
NPI:1417794215
Name:ROBERSON, JEFFREY WAYNE
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WAYNE
Last Name:ROBERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ALEWINE ST
Mailing Address - Street 2:
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35956-3021
Mailing Address - Country:US
Mailing Address - Phone:256-490-1003
Mailing Address - Fax:
Practice Address - Street 1:100 ALEWINE ST
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35956-3021
Practice Address - Country:US
Practice Address - Phone:256-490-1003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-124441363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health