Provider Demographics
NPI:1508157421
Name:ROBERTSON, JERRY ALVIN (MS)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:ALVIN
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2218 BRIDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4105
Mailing Address - Country:US
Mailing Address - Phone:907-799-2519
Mailing Address - Fax:
Practice Address - Street 1:3830 S CUSHMAN ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7530
Practice Address - Country:US
Practice Address - Phone:907-455-1416
Practice Address - Fax:907-455-1460
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker