Provider Demographics
NPI:1003675026
Name:ROBERTSON, JESSE RAY
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:RAY
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 1:2366 E CECIL CIR
Mailing Address - Street 2:
Mailing Address - City:GLOBE
Mailing Address - State:AZ
Mailing Address - Zip Code:85501-1458
Mailing Address - Country:US
Mailing Address - Phone:928-259-4864
Mailing Address - Fax:
Practice Address - Street 1:2366 E CECIL CIR
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-1458
Practice Address - Country:US
Practice Address - Phone:928-259-4864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)