Provider Demographics
NPI:1659730877
Name:SUBA, JASODRA
Entity Type:Individual
Prefix:
First Name:JASODRA
Middle Name:
Last Name:SUBA
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 1:1262 STONEWATER CIR
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-8610
Mailing Address - Country:US
Mailing Address - Phone:407-970-1350
Mailing Address - Fax:
Practice Address - Street 1:1262 STONEWATER CIR
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-8610
Practice Address - Country:US
Practice Address - Phone:407-970-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-16
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH13823101YM0800X
FLMH13823101YM0800X
FLMH20684101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health