Provider Demographics
NPI:1316406572
Name:ROBERTSON, JARED YOUNG IV
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:YOUNG
Last Name:ROBERTSON
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 HOUMA BLVD
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2970
Mailing Address - Country:US
Mailing Address - Phone:504-503-6781
Mailing Address - Fax:504-503-5667
Practice Address - Street 1:4200 HOUMA BLVD FL 6
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-2970
Practice Address - Country:US
Practice Address - Phone:504-503-4331
Practice Address - Fax:504-503-4341
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA330711207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program