Most Relevant Information
Provider Data
| NPI Number: | 1003418625 |
| Provider Name: | ROBERTA MARIE JACKSON |
| Entity Type: | Individual |
| Taxonomy Code: | 3747P1801X |
| Specialty: | Technician |
| License Number: |
Most Important Dates
| Enumeration Date: | 11/09/2020 |
| Last Updated: | 11/09/2020 |
Provider Practice Location
47 CHURCH ST
PHILIPPI
WV
264161103
Practice Location Phone/Fax
| Phone: | 3044574545 |
| Fax: |
Provider Mailing Location
PO BOX 146
PHILIPPI
WV
264160146
Provider Mailing Phone/Fax
| Phone: | 3044574545 |
| Fax: |