Provider Demographics
NPI:1477633493
Name:KUBIAK, JEANNINE MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEANNINE
Middle Name:MARIE
Last Name:KUBIAK
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 1:4832 E MICHIGAN ST APT 8
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32812-5411
Mailing Address - Country:US
Mailing Address - Phone:239-292-9379
Mailing Address - Fax:
Practice Address - Street 1:5201 RAYMOND ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-8208
Practice Address - Country:US
Practice Address - Phone:407-629-1599
Practice Address - Fax:407-599-1583
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY-6636103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU0401YMedicare ID - Type Unspecified