Provider Demographics
NPI:1053664177
Name:KUBIS, JACQUELINE ANN (SLP- CFY)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:KUBIS
Suffix:
Gender:F
Credentials:SLP- CFY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 SHERIDAN ROAD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-1995
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3415 SHERIDAN ROAD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-1995
Practice Address - Country:US
Practice Address - Phone:262-653-2941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3753-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist