Provider Demographics
NPI:1932212438
Name:ROBERTSON, BOBBY JACK JR (DC)
Entity Type:Individual
Prefix:DR
First Name:BOBBY
Middle Name:JACK
Last Name:ROBERTSON
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1536 JEFFCO BLVD
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010
Mailing Address - Country:US
Mailing Address - Phone:636-287-2200
Mailing Address - Fax:636-287-2201
Practice Address - Street 1:1536 JEFFCO BLVD
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010
Practice Address - Country:US
Practice Address - Phone:636-287-2200
Practice Address - Fax:636-287-2201
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002019220111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
5283529OtherAETNA
168022OtherBCBS
397682OtherHEALTHLINK
648230OtherUNITED HEALTH CARE
5283529OtherAETNA
648230OtherUNITED HEALTH CARE