Basic Information
| Provider Information | |||||||||
| NPI: | 1023369618 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | JESSICA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4520 N CENTRAL AVE | ||||||||
| Address2: | SUITE 602 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850121828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022795262 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4520 N CENTRAL AVE | ||||||||
| Address2: | STE 350 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850121828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022795262 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2012 | ||||||||
| LastUpdateDate: | 09/24/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 13696 | AZ | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.