Provider Demographics
NPI:1962740860
Name:ROBERTS, JENNIFER PAIGE (MA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:PAIGE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4109 CONVERSE DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-5933
Mailing Address - Country:US
Mailing Address - Phone:919-413-7192
Mailing Address - Fax:
Practice Address - Street 1:4109 CONVERSE DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-5933
Practice Address - Country:US
Practice Address - Phone:919-413-7192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2039103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities