Healthcare Provider Details

I. General information

NPI: 1356351613
Provider Name (Legal Business Name): JENNIFER E. ROBERTSON MCD, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16893 HYDRICK RD
CHERRY VALLEY AR
72324-8703
US

IV. Provider business mailing address

16893 HYDRICK RD
CHERRY VALLEY AR
72324-8703
US

V. Phone/Fax

Practice location:
  • Phone: 870-588-7372
  • Fax: 870-588-4782
Mailing address:
  • Phone: 870-588-7372
  • Fax: 870-588-4782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1871
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: