Provider Demographics
NPI:1265428734
Name:ROBERTSON, JARED Y III (CRNA)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:Y
Last Name:ROBERTSON
Suffix:III
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:149 DRINKWATER RD
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-1658
Practice Address - Country:US
Practice Address - Phone:228-467-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10597367500000X
LA5201367500000X
KY4858A367500000X
VA24167318367500000X
SC3625367500000X
NC71550367500000X
TX144482367500000X
MS901491367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010103894Medicaid
4081487OtherBLUE SHIELD OF TN
KY74008541Medicaid
TN0100OtherJOHN DEERE
TN100045319Medicaid
TN3632282Medicaid
00013859OtherNHC CARE ADMINISTRATORS
146158OtherANTHEM BCBS
P00153862Medicare ID - Type UnspecifiedRAILROAD MEDICARE
VAMC10052Medicare PIN
00013859OtherNHC CARE ADMINISTRATORS