Provider Demographics
NPI:1114484110
Name:ROBERSON, JACKIE LYNETTE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYNETTE
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:LYNETTE
Other - Last Name:TIJERINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5302 ARTISTIC CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-2212
Mailing Address - Country:US
Mailing Address - Phone:512-567-9565
Mailing Address - Fax:
Practice Address - Street 1:3727 PARKER BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2218
Practice Address - Country:US
Practice Address - Phone:719-585-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORTL.0005892227900000X
COOT.0005855225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered