Provider Demographics
NPI:1114970191
Name:SUDBRACK, JENNIFER L (PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:SUDBRACK
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 1:502 FARRELL DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3717
Mailing Address - Country:US
Mailing Address - Phone:859-331-3292
Mailing Address - Fax:859-578-2468
Practice Address - Street 1:722 SCOTT ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-2418
Practice Address - Country:US
Practice Address - Phone:859-431-2225
Practice Address - Fax:859-578-2388
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1349103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0256OtherMEDICARE