MEDICARE: MS. JENNIFER SUZANNE ROBERTS MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	39084	CA

General Provider Information

NPI Number	:	1881929875
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER SUZANNE ROBERTS MFT

Provider Business Mailing Address
First Line	:	PO BOX 2600
Second Line	:
City	:	BORREGO SPRINGS
State	:	CA
Zip	:	92004-2600
Country	:	US
Telephone Number	:	760-533-9049
Fax Number	:

Provider Business Practice Location Address
First Line	:	2907 WASHINGTON STREET
Second Line	:	STE B
City	:	JULIAN
State	:	CA
Zip	:	92036
Country	:	US
Telephone Number	:	760-533-9049
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2009
Last Update Date	:	10/08/2009

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