Provider Demographics
NPI:1275968711
Name:RUBACK, JENNA ANN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:ANN
Last Name:RUBACK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
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Other - Credentials:
Mailing Address - Street 1:11301 WILSHIRE BLVD
Mailing Address - Street 2:AUDIOLOGY & SPEECH PATHOLOGY SERVICE (126)
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90073-1003
Mailing Address - Country:US
Mailing Address - Phone:310-268-3701
Mailing Address - Fax:310-268-4791
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:AUDIOLOGY & SPEECH PATHOLOGY SERVICE (126)
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-268-3701
Practice Address - Fax:310-268-4791
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CASP19600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist