Healthcare Provider Details

I. General information

NPI: 1528223005
Provider Name (Legal Business Name): JENNIFER REBECCA ROBERTS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 07/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 N 15TH AVE
LAUREL MS
39440-2656
US

IV. Provider business mailing address

1008 N 15TH AVE
LAUREL MS
39440-2656
US

V. Phone/Fax

Practice location:
  • Phone: 601-649-5421
  • Fax: 601-426-3690
Mailing address:
  • Phone: 601-649-5421
  • Fax: 601-426-3690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number21751
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: