Basic Information
| Provider Information | |||||||||
| NPI: | 1639453962 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | JEANETTE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 351750 | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800351750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034848404 | ||||||||
| FaxNumber: | 7206394807 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 EXEMPLA CIR | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800263370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036894444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2011 | ||||||||
| LastUpdateDate: | 05/13/2016 | ||||||||
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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 | 207P00000X | 56204 | CO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 97850063 | 05 | CO | MEDICAID |