Provider Demographics
NPI:1689147613
Name:ROBERSON, JENNIFER E
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 MAPLE LN TRLR 19
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-7467
Mailing Address - Country:US
Mailing Address - Phone:206-247-8272
Mailing Address - Fax:
Practice Address - Street 1:21851 84TH AVE S STE 101
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-1958
Practice Address - Country:US
Practice Address - Phone:425-687-7082
Practice Address - Fax:425-687-7352
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60772248101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor