Basic Information
| Provider Information | |||||||||
| NPI: | 1750861779 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | WESLEY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 640 S STATE ST | ||||||||
| Address2: | MAIL CODE 3055 | ||||||||
| City: | DOVER | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199013530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3024801688 | ||||||||
| FaxNumber: | 3024809807 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 BANNING ST | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199043485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027341414 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2018 | ||||||||
| LastUpdateDate: | 07/29/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C5-0001235 | DE | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.