Provider Demographics
NPI:1013381904
Name:SUBA, JENNIFER S (P T)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:SUBA
Suffix:
Gender:F
Credentials:P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15109 DECLARATION DR
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-8080
Mailing Address - Country:US
Mailing Address - Phone:317-414-6410
Mailing Address - Fax:
Practice Address - Street 1:15109 DECLARATION DR
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-8080
Practice Address - Country:US
Practice Address - Phone:317-414-6410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007192A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist