Provider Demographics
NPI:1922564913
Name:ROBERTSON, JACOB ANDREW (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:ANDREW
Last Name:ROBERTSON
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 1:603 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-4317
Mailing Address - Country:US
Mailing Address - Phone:731-608-5637
Mailing Address - Fax:
Practice Address - Street 1:603 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4317
Practice Address - Country:US
Practice Address - Phone:731-608-5637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1160504OtherNCCPA
NY024715-01OtherNEW YORK STATE LICENSE