Healthcare Provider Details

I. General information

NPI: 1265428734
Provider Name (Legal Business Name): JARED Y ROBERTSON III CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 DRINKWATER RD
BAY ST LOUIS MS
39520-1658
US

IV. Provider business mailing address

1514 JEFFERSON HWY
NEW ORLEANS LA
70121-2429
US

V. Phone/Fax

Practice location:
  • Phone: 228-467-8600
  • Fax:
Mailing address:
  • Phone: 504-842-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number10597
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number5201
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4858A
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number24167318
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3625
License Number StateSC
# 6
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number71550
License Number StateNC
# 7
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number144482
License Number StateTX
# 8
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number901491
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: