Provider Demographics
NPI:1871760751
Name:ROBERTS, JACOB ODELL (DC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ODELL
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-5854
Mailing Address - Country:US
Mailing Address - Phone:317-924-5250
Mailing Address - Fax:
Practice Address - Street 1:2413 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208
Practice Address - Country:US
Practice Address - Phone:317-924-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-10
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10798111N00000X
IN08002512A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor