Provider Demographics
NPI:1033413646
Name:GRUBA, JENNIFER R (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:GRUBA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N. WEBB AVE
Mailing Address - Street 2:
Mailing Address - City:REEDSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53959
Mailing Address - Country:US
Mailing Address - Phone:608-524-5151
Mailing Address - Fax:608-524-5353
Practice Address - Street 1:2901 HUNTERS TRL
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-3403
Practice Address - Country:US
Practice Address - Phone:608-742-5518
Practice Address - Fax:608-742-4087
Is Sole Proprietor?:No
Enumeration Date:2010-12-23
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI867-124106H00000X
WI5149-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist