Basic Information
Provider Information | |||||||||
NPI: | 1811411218 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERTS | ||||||||
FirstName: | JACOB | ||||||||
MiddleName: | SCOTT | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 37 FRIEND STREET | ||||||||
Address2: | ELEMENT CARE INC. | ||||||||
City: | LYNN | ||||||||
State: | MA | ||||||||
PostalCode: | 01902 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7817156608 | ||||||||
FaxNumber: | 7817156699 | ||||||||
Practice Location | |||||||||
Address1: | 12 INGALLS COURT | ||||||||
Address2: |   | ||||||||
City: | METHOEN | ||||||||
State: | MA | ||||||||
PostalCode: | 01844 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9786862807 | ||||||||
FaxNumber: | 9786874148 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2017 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN242898 | MA | Y |   | Nursing Service Providers | Registered Nurse |   |
No ID Information.