Provider Demographics
NPI:1891754255
Name:ROBERTSON, KATHERINE JEAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:JEAN
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:VAN PATTEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:5100 OBYRNES FERRY RD
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:CA
Mailing Address - Zip Code:95327-9102
Mailing Address - Country:US
Mailing Address - Phone:209-984-5291
Mailing Address - Fax:
Practice Address - Street 1:5100 OBYRNES FERRY RD
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:CA
Practice Address - Zip Code:95327-9102
Practice Address - Country:US
Practice Address - Phone:209-984-5291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002362103T00000X
CAPSY21877103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAS92182Medicare UPIN