Provider Demographics
NPI:1871069153
Name:ROBERTSON, JARED LEVON (APRN)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:LEVON
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2249 BOREN BLVD
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:OK
Mailing Address - Zip Code:74868-1927
Mailing Address - Country:US
Mailing Address - Phone:405-584-8888
Mailing Address - Fax:833-641-2432
Practice Address - Street 1:2249 BOREN BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868-1927
Practice Address - Country:US
Practice Address - Phone:405-584-8888
Practice Address - Fax:833-641-2432
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS78426363L00000X
OK106806363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner