Provider Demographics
NPI:1760025225
Name:ROBERTS, JAZMIN NECOLE (LPN)
Entity Type:Individual
Prefix:
First Name:JAZMIN
Middle Name:NECOLE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 SWAN ST FL 1
Mailing Address - Street 2:
Mailing Address - City:GREEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12183-1401
Mailing Address - Country:US
Mailing Address - Phone:518-443-9159
Mailing Address - Fax:
Practice Address - Street 1:52 CORPORATE CIR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-5176
Practice Address - Country:US
Practice Address - Phone:518-456-4466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY314061164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse