Provider Demographics
NPI:1578068110
Name:ROBERTS, JODEE M (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JODEE
Middle Name:M
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19928 KUPER CT
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-9665
Mailing Address - Country:US
Mailing Address - Phone:509-741-0414
Mailing Address - Fax:
Practice Address - Street 1:813 ESHOM RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-1515
Practice Address - Country:US
Practice Address - Phone:360-330-7605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2000014984OtherBOC CERTIFICATION NUMBER
48449OtherNATA MEMBERSHIP NUMBER