Provider Demographics
NPI:1134409311
Name:ROBERTS, JEFFREY A
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JEFF
Other - Middle Name:
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:15 CLINTON ST
Mailing Address - Street 2:5
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-5944
Mailing Address - Country:US
Mailing Address - Phone:508-808-8111
Mailing Address - Fax:
Practice Address - Street 1:118 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-5465
Practice Address - Country:US
Practice Address - Phone:781-891-0556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health