Provider Demographics
NPI:1760214100
Name:ROBERTSON, JACKQUELINE L (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:JACKQUELINE
Middle Name:L
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 205
Mailing Address - Street 2:
Mailing Address - City:THICKET
Mailing Address - State:TX
Mailing Address - Zip Code:77374-0205
Mailing Address - Country:US
Mailing Address - Phone:520-425-0739
Mailing Address - Fax:
Practice Address - Street 1:3080 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-4606
Practice Address - Country:US
Practice Address - Phone:409-212-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-15
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1172149363LG0600X, 363LA2100X
TX690734251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No251J00000XAgenciesNursing Care