Provider Demographics
NPI:1538934674
Name:ROBERTS, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5522 TAYLOR MILL RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR MILL
Mailing Address - State:KY
Mailing Address - Zip Code:41015-4604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5522 TAYLOR MILL RD
Practice Address - Street 2:
Practice Address - City:TAYLOR MILL
Practice Address - State:KY
Practice Address - Zip Code:41015-4604
Practice Address - Country:US
Practice Address - Phone:855-444-5664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician