Provider Demographics
NPI:1134400021
Name:ROBERTS, JEANEEN ANN (LMT)
Entity type:Individual
Prefix:MS
First Name:JEANEEN
Middle Name:ANN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8631 141ST ST
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-5291
Mailing Address - Country:US
Mailing Address - Phone:715-829-9794
Mailing Address - Fax:
Practice Address - Street 1:534 WATER ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-5631
Practice Address - Country:US
Practice Address - Phone:715-829-9794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3902-146174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist