Provider Demographics
NPI:1609390087
Name:KUBACIK, JENNIFER CYNTHIA (OT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CYNTHIA
Last Name:KUBACIK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-7401
Mailing Address - Country:US
Mailing Address - Phone:815-337-7100
Mailing Address - Fax:815-337-4793
Practice Address - Street 1:2000 LAKE AVE
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-7401
Practice Address - Country:US
Practice Address - Phone:815-337-7100
Practice Address - Fax:815-337-4793
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
IL056010930225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist