Healthcare Provider Details

I. General information

NPI: 1912304478
Provider Name (Legal Business Name): JESSICA ROBLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2014
Last Update Date: 11/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4923 LYNCOTT DR
LANSING MI
48910-5636
US

IV. Provider business mailing address

4923 LYNCOTT DR
LANSING MI
48910-5636
US

V. Phone/Fax

Practice location:
  • Phone: 517-402-4163
  • Fax:
Mailing address:
  • Phone: 517-402-4163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: