Provider Demographics
NPI:1992176556
Name:ROBERTSON, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 W 70TH ST
Mailing Address - Street 2:APT 2401
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-2500
Mailing Address - Country:US
Mailing Address - Phone:318-762-7526
Mailing Address - Fax:318-226-5994
Practice Address - Street 1:6000 W 70TH ST
Practice Address - Street 2:APT 2401
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-2500
Practice Address - Country:US
Practice Address - Phone:318-762-7526
Practice Address - Fax:318-226-5994
Is Sole Proprietor?:No
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator