Provider Demographics
NPI:1073946984
Name:GREDICEK, JENNIFER RUBIO (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RUBIO
Last Name:GREDICEK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 S CHURCH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LOCKHART
Mailing Address - State:TX
Mailing Address - Zip Code:78644-2713
Mailing Address - Country:US
Mailing Address - Phone:512-376-2999
Mailing Address - Fax:512-376-5562
Practice Address - Street 1:500 N CAPITAL OF TEXAS HWY # 6
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-3302
Practice Address - Country:US
Practice Address - Phone:855-481-8375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX642100364SF0001X
TXAP124084364SF0001X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX340893201Medicaid
TX343154YL9XMedicare PIN