Provider Demographics
NPI:1790272235
Name:RUBSAM, JACQUELYNN ANN (CNP)
Entity Type:Individual
Prefix:
First Name:JACQUELYNN
Middle Name:ANN
Last Name:RUBSAM
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15049 SYLVIA DR
Mailing Address - Street 2:
Mailing Address - City:BROOKPARK
Mailing Address - State:OH
Mailing Address - Zip Code:44142-3056
Mailing Address - Country:US
Mailing Address - Phone:216-513-0824
Mailing Address - Fax:
Practice Address - Street 1:15049 SYLVIA DR
Practice Address - Street 2:
Practice Address - City:BROOKPARK
Practice Address - State:OH
Practice Address - Zip Code:44142-3056
Practice Address - Country:US
Practice Address - Phone:216-513-0824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.022601363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily