Provider Demographics
NPI:1174678189
Name:ROBERTS, JACKIE (LPN)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E PROSSER RD LOT 11
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-3128
Mailing Address - Country:US
Mailing Address - Phone:307-635-3972
Mailing Address - Fax:
Practice Address - Street 1:300 E PROSSER RD LOT 11
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82007-3128
Practice Address - Country:US
Practice Address - Phone:307-635-3972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5526164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse