Healthcare Provider Details

I. General information

NPI: 1134732944
Provider Name (Legal Business Name): MRS. JAHNAE NICOLE ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2020
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 N COURT ST
WAMPSVILLE NY
13163-7714
US

IV. Provider business mailing address

138 N COURT ST
WAMPSVILLE NY
13163-7714
US

V. Phone/Fax

Practice location:
  • Phone: 315-366-2327
  • Fax:
Mailing address:
  • Phone: 315-366-2327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number113258-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: