Healthcare Provider Details

I. General information

NPI: 1871069153
Provider Name (Legal Business Name): JARED LEVON ROBERTSON APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2018
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2646 HIGHWAY 9 WEST
SEMINOLE OK
74868-6652
US

IV. Provider business mailing address

2646 HIGHWAY 9 W
SEMINOLE OK
74868-6652
US

V. Phone/Fax

Practice location:
  • Phone: 405-584-8888
  • Fax: 405-303-6099
Mailing address:
  • Phone: 405-584-8888
  • Fax: 405-303-6099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number106806
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number78426
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: