Provider Demographics
NPI:1740582485
Name:GRUBER, JENNIFER IRENE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:IRENE
Last Name:GRUBER
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 1:101 E FULTON ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67846-5454
Mailing Address - Country:US
Mailing Address - Phone:620-275-8400
Mailing Address - Fax:620-275-2687
Practice Address - Street 1:101 E FULTON ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846-5454
Practice Address - Country:US
Practice Address - Phone:620-275-8400
Practice Address - Fax:620-275-2687
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-01
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1402199225200000X
NE959225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant