Provider Demographics
NPI:1952696270
Name:ROBERTS, JACOB S (FMHNPI)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:S
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:FMHNPI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 N 1680 E
Mailing Address - Street 2:STE H1
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-2579
Mailing Address - Country:US
Mailing Address - Phone:435-652-1897
Mailing Address - Fax:435-652-5909
Practice Address - Street 1:230 N 1680 E
Practice Address - Street 2:SUITE H1
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2579
Practice Address - Country:US
Practice Address - Phone:435-652-1897
Practice Address - Fax:435-652-5909
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6874787-4408363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health