Healthcare Provider Details

I. General information

NPI: 1982771358
Provider Name (Legal Business Name): JACQUELYN R. ROBERSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 03/01/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HENRY FORD HEALTH SYSTEM 2799 WEST GRAND BOULEVARD
DETROIT MI
48202
US

IV. Provider business mailing address

HENRY FORD HEALTH SYSTEM 3031 WEST GRAND BOULEVARD SUITE 700
DETROIT MI
48202
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2436
  • Fax:
Mailing address:
  • Phone: 313-916-3115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301037509
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number4301037509
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: