Provider Demographics
NPI:1790080653
Name:ROBERTS, JACEY A (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JACEY
Middle Name:A
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JACEY
Other - Middle Name:A
Other - Last Name:BENNIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1412 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-2908
Mailing Address - Country:US
Mailing Address - Phone:215-599-4851
Mailing Address - Fax:215-232-4093
Practice Address - Street 1:1046 TULIP TER
Practice Address - Street 2:
Practice Address - City:ROCKINGHAM
Practice Address - State:VA
Practice Address - Zip Code:22801-5324
Practice Address - Country:US
Practice Address - Phone:540-421-0779
Practice Address - Fax:540-438-0023
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005554363A00000X
PAMA054722363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant