Provider Demographics
NPI:1528437662
Name:ROBERTS, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:ROBERTS
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 1:10814 WILKINS RD
Mailing Address - Street 2:
Mailing Address - City:ROUGEMONT
Mailing Address - State:NC
Mailing Address - Zip Code:27572
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10814 WILKINS RD
Practice Address - Street 2:
Practice Address - City:ROUGEMONT
Practice Address - State:NC
Practice Address - Zip Code:27572
Practice Address - Country:US
Practice Address - Phone:919-514-0418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10359171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC10359OtherMASSAGE LICENSE