1063654820 NPI number — DR. JEANETTE MICHELLE ROBERTSON PH.D., LCMFT

Table of content: DR. JEANETTE MICHELLE ROBERTSON PH.D., LCMFT (NPI 1063654820)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063654820 NPI number — DR. JEANETTE MICHELLE ROBERTSON PH.D., LCMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTSON
Provider First Name:
JEANETTE
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D., LCMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063654820
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 W UNIVERSITY AVE
Provider Second Line Business Mailing Address:
MARRIAGE AND FAMILY THERAPY
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67213-3379
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-295-5609
Provider Business Mailing Address Fax Number:
316-295-5115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 W UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
MARRIAGE AND FAMILY THERAPY
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67213-3379
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-295-5609
Provider Business Practice Location Address Fax Number:
316-295-5115
Provider Enumeration Date:
03/25/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  303 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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