Provider Demographics
NPI:1497107643
Name:ROBERTS, JAMIE DANIELLE (MA)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:DANIELLE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9135 ARCHIBALD AVE STE B
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5227
Mailing Address - Country:US
Mailing Address - Phone:424-272-1806
Mailing Address - Fax:
Practice Address - Street 1:9135 ARCHIBALD AVE STE B
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5227
Practice Address - Country:US
Practice Address - Phone:424-272-1806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF76975106H00000X
CALMFT96181106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
.OtherIEHP