Provider Demographics
NPI:1740761451
Name:ROBERSON, JASMINE ELISE (PTA)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:ELISE
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 VILLAGE ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75654-4528
Mailing Address - Country:US
Mailing Address - Phone:903-646-0372
Mailing Address - Fax:
Practice Address - Street 1:4616 NE STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1608
Practice Address - Country:US
Practice Address - Phone:936-569-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2140422225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant