Provider Demographics
NPI:1578513438
Name:ROBERTSON, JEFFREY R (LCSW)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6840 PRAIRIE RUN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-2665
Mailing Address - Country:US
Mailing Address - Phone:219-763-4767
Mailing Address - Fax:
Practice Address - Street 1:6840 PRAIRIE RUN AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-2665
Practice Address - Country:US
Practice Address - Phone:219-763-4767
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001418A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN658820Medicare ID - Type Unspecified