Provider Demographics
NPI:1366484214
Name:ROBERTS, JENNIFER L (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-2613
Mailing Address - Country:US
Mailing Address - Phone:941-485-1505
Mailing Address - Fax:941-485-7495
Practice Address - Street 1:3030 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-2613
Practice Address - Country:US
Practice Address - Phone:941-485-1505
Practice Address - Fax:941-485-7495
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102029363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291421200Medicaid
FLP74283Medicare UPIN
FL291421200Medicaid