Provider Demographics
NPI:1649870197
Name:ROBERTSON, JESSICA (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 SW 1ST LN
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:MO
Mailing Address - Zip Code:64759-1772
Mailing Address - Country:US
Mailing Address - Phone:417-682-3584
Mailing Address - Fax:417-682-3887
Practice Address - Street 1:29 SW 1ST LN
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:MO
Practice Address - Zip Code:64759-1772
Practice Address - Country:US
Practice Address - Phone:417-682-3584
Practice Address - Fax:417-682-3887
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016027157183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist