Provider Demographics
NPI:1427516236
Name:ROBERTS, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 MEMORIAL ST STE 1
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-2504
Mailing Address - Country:US
Mailing Address - Phone:509-786-2010
Mailing Address - Fax:509-788-1794
Practice Address - Street 1:820 MEMORIAL ST STE 1
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-2504
Practice Address - Country:US
Practice Address - Phone:509-786-2010
Practice Address - Fax:509-788-1794
Is Sole Proprietor?:No
Enumeration Date:2019-03-11
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP61587213207Q00000X
WAOL61162096207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine