Provider Demographics
NPI:1083929988
Name:ROBERTS, JENNY L (PA)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:L
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 GRESHAM DR
Mailing Address - Street 2:SUITE 8630B
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1904
Mailing Address - Country:US
Mailing Address - Phone:757-388-6115
Mailing Address - Fax:
Practice Address - Street 1:113 GAINSBOROUGH SQ STE 400
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-1714
Practice Address - Country:US
Practice Address - Phone:757-842-4499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003324363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAA102788Medicare PIN