Provider Demographics
NPI:1447058086
Name:ROBERTSON, JACQLYN PATRICE
Entity type:Individual
Prefix:
First Name:JACQLYN
Middle Name:PATRICE
Last Name:ROBERTSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 BIG ELK RD
Mailing Address - Street 2:
Mailing Address - City:WALLACE
Mailing Address - State:WV
Mailing Address - Zip Code:26448-8529
Mailing Address - Country:US
Mailing Address - Phone:304-844-1001
Mailing Address - Fax:
Practice Address - Street 1:2525 BIG ELK RD
Practice Address - Street 2:
Practice Address - City:WALLACE
Practice Address - State:WV
Practice Address - Zip Code:26448-8529
Practice Address - Country:US
Practice Address - Phone:304-844-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant