Basic Information
| Provider Information | |||||||||
| NPI: | 1316406572 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | JARED | ||||||||
| MiddleName: | YOUNG | ||||||||
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| NameSuffix: | IV | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 HOUMA BLVD | ||||||||
| Address2: | MEDICAL STAFF SERVICES | ||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700062970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5045036781 | ||||||||
| FaxNumber: | 5045035667 | ||||||||
| Practice Location | |||||||||
| Address1: | 4200 HOUMA BLVD FL 6 | ||||||||
| Address2: | |||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700062970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5045034331 | ||||||||
| FaxNumber: | 5045034341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2019 | ||||||||
| LastUpdateDate: | 07/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 330711 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.