Provider Demographics
NPI:1699862789
Name:ROBERTS, JENNIFER (PHD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
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 1:19 OLD TOWN SQ
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-2471
Mailing Address - Country:US
Mailing Address - Phone:646-526-3116
Mailing Address - Fax:970-482-0251
Practice Address - Street 1:19 OLD TOWN SQ
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-2471
Practice Address - Country:US
Practice Address - Phone:646-526-3116
Practice Address - Fax:970-482-0251
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-09
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3726103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical