Provider Demographics
NPI:1952802084
Name:ROBERSON, JALISA
Entity Type:Individual
Prefix:
First Name:JALISA
Middle Name:
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 DAVIS PL
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-6839
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5135 CAMINO AL NORTE STE 150
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-2388
Practice Address - Country:US
Practice Address - Phone:702-853-6714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV372500000X, 372600000X, 3747A0650X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider