Provider Demographics
NPI:1760157903
Name:ROBERTSON, JALEN ALEXANDER
Entity Type:Individual
Prefix:
First Name:JALEN
Middle Name:ALEXANDER
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4414 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70802-1448
Mailing Address - Country:US
Mailing Address - Phone:225-778-7678
Mailing Address - Fax:
Practice Address - Street 1:3173 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70802-2178
Practice Address - Country:US
Practice Address - Phone:225-778-7678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician