Healthcare Provider Details

I. General information

NPI: 1194976100
Provider Name (Legal Business Name): JEFFREY R ROBERTSON INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 02/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6840 PRAIRIE RUN AVE
PORTAGE IN
46368-2665
US

IV. Provider business mailing address

6840 PRAIRIE RUN AVE
PORTAGE IN
46368-2665
US

V. Phone/Fax

Practice location:
  • Phone: 219-763-4767
  • Fax:
Mailing address:
  • Phone: 219-763-4767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number34001418A
License Number StateIN

VIII. Authorized Official

Name: MR. JEFFREY R ROBERTSON
Title or Position: LCSW
Credential: LCSW
Phone: 219-763-4767