Provider Demographics
NPI:1659652576
Name:JENNIFER B. ROBERTS, MD, PLLC
Entity Type:Organization
Organization Name:JENNIFER B. ROBERTS, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-310-3843
Mailing Address - Street 1:PO BOX 248855
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73124-8855
Mailing Address - Country:US
Mailing Address - Phone:405-310-3843
Mailing Address - Fax:405-321-5348
Practice Address - Street 1:2413 PALMER CIR
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6301
Practice Address - Country:US
Practice Address - Phone:405-310-3843
Practice Address - Fax:405-321-5348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-06
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25719174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1871799619OtherINDIVIDUAL NPI