Provider Demographics
NPI:1275244469
Name:RUBIO, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:RUBIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11375 SW DISCOVERY WAY APT 206
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2567
Mailing Address - Country:US
Mailing Address - Phone:386-848-7507
Mailing Address - Fax:
Practice Address - Street 1:840 SE OSCEOLA ST
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2432
Practice Address - Country:US
Practice Address - Phone:772-291-1614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA18161224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOTA18161OtherOCCUPATIONAL THERAPY ASSISTANT