Provider Demographics
NPI:1699331694
Name:ROBERSON, JACQUELYN RANAE (LPN)
Entity type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:RANAE
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:JACQUELYN
Other - Middle Name:RANAE
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:3341 YOUREE DR STE 205
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2149
Mailing Address - Country:US
Mailing Address - Phone:318-219-4167
Mailing Address - Fax:
Practice Address - Street 1:3341 YOUREE DR STE 205
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2149
Practice Address - Country:US
Practice Address - Phone:318-219-4167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA20170350164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse