Provider Demographics
NPI:1912102872
Name:ROBERTS, JENIFER ELLEN (ATC)
Entity Type:Individual
Prefix:MISS
First Name:JENIFER
Middle Name:ELLEN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5616 LA ROCHE AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-3115
Mailing Address - Country:US
Mailing Address - Phone:912-656-8352
Mailing Address - Fax:
Practice Address - Street 1:5616 LA ROCHE AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3115
Practice Address - Country:US
Practice Address - Phone:912-656-8352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0007672255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer