Provider Demographics
NPI:1225259369
Name:ROBERTSON, JEAN GRACE (LSW)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:GRACE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 4TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-2418
Mailing Address - Country:US
Mailing Address - Phone:701-662-4913
Mailing Address - Fax:701-662-4963
Practice Address - Street 1:420 4TH AVE NE
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-2418
Practice Address - Country:US
Practice Address - Phone:701-662-4913
Practice Address - Fax:701-662-4963
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3486104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker