Provider Demographics
NPI:1306199625
Name:ROBERTS, JASON DAVIDSON (FNP)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DAVIDSON
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2073 OLYMPIC ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-3413
Mailing Address - Country:US
Mailing Address - Phone:541-682-3550
Mailing Address - Fax:541-682-3551
Practice Address - Street 1:2073 OLYMPIC ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-3413
Practice Address - Country:US
Practice Address - Phone:541-682-3550
Practice Address - Fax:541-682-3551
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201507389NP-PP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner