Provider Demographics
NPI:1386647071
Name:ROBERTS, JEFFREY ALAN (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALAN
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-1362
Mailing Address - Country:US
Mailing Address - Phone:270-692-6555
Mailing Address - Fax:270-692-5751
Practice Address - Street 1:496 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1362
Practice Address - Country:US
Practice Address - Phone:270-692-6555
Practice Address - Fax:270-692-5751
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4427111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6080601Medicare ID - Type Unspecified
KYU70139Medicare UPIN