Provider Demographics
NPI:1497162986
Name:ROBERTS, JEFFREY (LPN,WCN)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:LPN,WCN
Other - Prefix:MR
Other - First Name:JEFFREY
Other - Middle Name:DONALD
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN, WCN
Mailing Address - Street 1:620 S ELDER ST
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-5212
Mailing Address - Country:US
Mailing Address - Phone:208-465-7659
Mailing Address - Fax:
Practice Address - Street 1:620 S ELDER ST
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5212
Practice Address - Country:US
Practice Address - Phone:208-465-7659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPN-15716164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse