Provider Demographics
NPI:1811639057
Name:ROBERTSON, JENNA-PAIX (CLC)
Entity type:Individual
Prefix:MRS
First Name:JENNA-PAIX
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5741 CLEVELAND ST STE 150
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1777
Mailing Address - Country:US
Mailing Address - Phone:757-422-5502
Mailing Address - Fax:
Practice Address - Street 1:5741 CLEVELAND ST STE 150
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-1777
Practice Address - Country:US
Practice Address - Phone:757-422-5502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-08
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA316744174N00000X
VA315760174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No174N00000XOther Service ProvidersLactation Consultant, Non-RN