Provider Demographics
NPI:1851274922
Name:ROBERTSON, JAKOB WYLLYS ENRIQUE
Entity type:Individual
Prefix:
First Name:JAKOB
Middle Name:WYLLYS ENRIQUE
Last Name:ROBERTSON
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 1:1400 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2134
Mailing Address - Country:US
Mailing Address - Phone:877-876-3627
Mailing Address - Fax:321-841-3794
Practice Address - Street 1:1400 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2134
Practice Address - Country:US
Practice Address - Phone:877-876-3627
Practice Address - Fax:321-841-3794
Is Sole Proprietor?:No
Enumeration Date:2025-07-28
Last Update Date:2025-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9120887363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant