Provider Demographics
NPI:1134548431
Name:ROBERTSON, JEROME DOYLE (BS)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:DOYLE
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12601 N PENN AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-9405
Mailing Address - Country:US
Mailing Address - Phone:405-213-3973
Mailing Address - Fax:
Practice Address - Street 1:12601 N PENN AVE APT 202
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-9405
Practice Address - Country:US
Practice Address - Phone:405-213-3973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor