Provider Demographics
NPI:1649684416
Name:ROBERTS, JENNIFER DANICE
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:DANICE
Last Name:ROBERTS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 SAFFRON LANE
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-8976
Mailing Address - Country:US
Mailing Address - Phone:678-502-0521
Mailing Address - Fax:
Practice Address - Street 1:404 SAFFRON LANE
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252
Practice Address - Country:US
Practice Address - Phone:678-502-0521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10673235Z00000X
GA008655235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA06192014925817OtherTRACKING ID