Healthcare Provider Details

I. General information

NPI: 1427516236
Provider Name (Legal Business Name): JESSICA ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2019
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 MEMORIAL ST STE 1
PROSSER WA
99350-2504
US

IV. Provider business mailing address

820 MEMORIAL ST STE 1
PROSSER WA
99350-2504
US

V. Phone/Fax

Practice location:
  • Phone: 509-786-2010
  • Fax: 509-788-1794
Mailing address:
  • Phone: 509-786-2010
  • Fax: 509-788-1794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP61587213
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOL61162096
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: