Provider Demographics
NPI:1427556802
Name:ROBERTS, JAMILA IFE (PTA)
Entity Type:Individual
Prefix:
First Name:JAMILA
Middle Name:IFE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JAMILA
Other - Middle Name:IFE
Other - Last Name:BURNETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:58564 BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-6238
Mailing Address - Country:US
Mailing Address - Phone:574-214-6040
Mailing Address - Fax:
Practice Address - Street 1:3109 E BRISTOL ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-4372
Practice Address - Country:US
Practice Address - Phone:574-330-4004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004225A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant