Provider Demographics
NPI:1134719743
Name:ROBERTS, JADE ALEXANDRA
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:ALEXANDRA
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 MCDONALD DR APT E
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5388
Mailing Address - Country:US
Mailing Address - Phone:601-517-1531
Mailing Address - Fax:
Practice Address - Street 1:2507A OLD BRANDON RD
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-4604
Practice Address - Country:US
Practice Address - Phone:601-345-2124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903844363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily