Provider Demographics
NPI:1407070816
Name:ROBERTSON, JERRI DAWN (DO)
Entity Type:Individual
Prefix:DR
First Name:JERRI
Middle Name:DAWN
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 KIDWELL DR
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:MO
Mailing Address - Zip Code:65084-1784
Mailing Address - Country:US
Mailing Address - Phone:573-378-4666
Mailing Address - Fax:573-378-5099
Practice Address - Street 1:901 KIDWELL DR
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:MO
Practice Address - Zip Code:65084-1784
Practice Address - Country:US
Practice Address - Phone:573-378-4666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006018426207Q00000X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM