Healthcare Provider Details

I. General information

NPI: 1376195404
Provider Name (Legal Business Name): JENNA L ROBERTSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2019
Last Update Date: 11/19/2022
Certification Date: 11/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 SHABER RD
PATCHOGUE NY
11772-1126
US

IV. Provider business mailing address

46 SHABER RD
PATCHOGUE NY
11772-1126
US

V. Phone/Fax

Practice location:
  • Phone: 516-567-3813
  • Fax:
Mailing address:
  • Phone: 516-567-3813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number119076-01
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: