Provider Demographics
NPI:1497050553
Name:ROBERTS, JESSE LEON (DC)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:LEON
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 1:12495 OLD HALLS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-4201
Mailing Address - Country:US
Mailing Address - Phone:314-330-9474
Mailing Address - Fax:
Practice Address - Street 1:1701 S FLORISSANT RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-1131
Practice Address - Country:US
Practice Address - Phone:314-522-0042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009011872111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor