Provider Demographics
NPI:1043691173
Name:ROBERTSON, JAYME RIVAS (EDM)
Entity Type:Individual
Prefix:
First Name:JAYME
Middle Name:RIVAS
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:EDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:848 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01701-4815
Mailing Address - Country:US
Mailing Address - Phone:508-879-5110
Mailing Address - Fax:
Practice Address - Street 1:848 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01701-4815
Practice Address - Country:US
Practice Address - Phone:508-879-5110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA415825174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist