Healthcare Provider Details

I. General information

NPI: 1104168459
Provider Name (Legal Business Name): JESSIELA VENIS ROBERTS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 S 12TH ST
FORT SMITH AR
72901-4702
US

IV. Provider business mailing address

410 W BRINKLEY LOOP APT. 2
MARION AR
72364-5033
US

V. Phone/Fax

Practice location:
  • Phone: 479-785-2431
  • Fax: 479-785-0732
Mailing address:
  • Phone: 914-325-2103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-9138
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberE-9138
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: