Provider Demographics
NPI:1114030558
Name:RUBENSTEIN, JODY ALAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JODY
Middle Name:ALAN
Last Name:RUBENSTEIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5418 MORNINGSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-5840
Mailing Address - Country:US
Mailing Address - Phone:214-206-6473
Mailing Address - Fax:
Practice Address - Street 1:5418 MORNINGSIDE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-5840
Practice Address - Country:US
Practice Address - Phone:214-206-6473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-4753103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX89455AOtherBLUE CROSS BLUE SHIELD
TX352153601Medicaid
TX352153602OtherCSHCN MEDICAID
TX00L54AMedicare UPIN
TX352153601Medicaid
TXR58457Medicare UPIN