Provider Demographics
NPI:1669841656
Name:ROBERSON, JERRY LYNN (PHD NMD RRT RCP-NPS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LYNN
Last Name:ROBERSON
Suffix:
Gender:M
Credentials:PHD NMD RRT RCP-NPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 LOYADELL ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-6762
Mailing Address - Country:US
Mailing Address - Phone:209-679-8057
Mailing Address - Fax:888-476-8693
Practice Address - Street 1:1118 LOYADELL ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-6762
Practice Address - Country:US
Practice Address - Phone:209-679-8057
Practice Address - Fax:888-476-8693
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-19
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ZZ0813175F00000X
TX9692 AND 716562279E0002X, 2278E1000X
CA9692 AND 716562279C0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No175F00000XOther Service ProvidersNaturopath
No2279E0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredEmergency Care
No2278E1000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedEducational
No2279C0205XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredCritical Care