Provider Demographics
NPI:1376592667
Name:ROBERTS, JACK T (AUD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:T
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 COOPER FOSTER PARK RD W
Mailing Address - Street 2:SUITE A
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-3657
Mailing Address - Country:US
Mailing Address - Phone:440-989-1133
Mailing Address - Fax:440-989-1137
Practice Address - Street 1:1680 COOPER FOSTER PARK RD W
Practice Address - Street 2:SUITE A
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3657
Practice Address - Country:US
Practice Address - Phone:440-989-1133
Practice Address - Fax:440-989-1137
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA00803231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0883076Medicaid
OHRO-0712071Medicare ID - Type Unspecified