Healthcare Provider Details

I. General information

NPI: 1528423050
Provider Name (Legal Business Name): JENENE ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2015
Last Update Date: 01/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 LABELLE LN SW
MARIETTA GA
30060-5555
US

IV. Provider business mailing address

140 LABELLE LN SW
MARIETTA GA
30060-5555
US

V. Phone/Fax

Practice location:
  • Phone: 770-403-3120
  • Fax:
Mailing address:
  • Phone: 770-403-3120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN140714
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN140714
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: