Healthcare Provider Details

I. General information

NPI: 1245027648
Provider Name (Legal Business Name): JERMAINE CULDRICK ROBERTSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 NICOLLET AVE
MINNEAPOLIS MN
55408-4708
US

IV. Provider business mailing address

701 PARK AVE
MINNEAPOLIS MN
55415-1623
US

V. Phone/Fax

Practice location:
  • Phone: 613-873-8084
  • Fax:
Mailing address:
  • Phone: 631-874-3000
  • Fax: 631-874-3000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: