Provider Demographics
NPI:1376195404
Name:ROBERTSON, JENNA L
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:L
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 SHABER RD
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-1126
Mailing Address - Country:US
Mailing Address - Phone:516-567-3813
Mailing Address - Fax:
Practice Address - Street 1:46 SHABER RD
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1126
Practice Address - Country:US
Practice Address - Phone:516-567-3813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2022-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NY119076-01235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator