Provider Demographics
NPI:1750861779
Name:ROBERTS, JACOB WESLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:WESLEY
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 THEATRE DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-2838
Mailing Address - Country:US
Mailing Address - Phone:814-266-3934
Mailing Address - Fax:814-266-3934
Practice Address - Street 1:411 THEATRE DR
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-2838
Practice Address - Country:US
Practice Address - Phone:814-266-3934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061665363A00000X
DEC5-0001235363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant