Provider Demographics
NPI:1891268843
Name:TUBBS, JENNIE (BS, CTRS, CDP)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:TUBBS
Suffix:
Gender:F
Credentials:BS, CTRS, CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:FRUITPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49415-9602
Mailing Address - Country:US
Mailing Address - Phone:616-477-5618
Mailing Address - Fax:
Practice Address - Street 1:147 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:FRUITPORT
Practice Address - State:MI
Practice Address - Zip Code:49415-9602
Practice Address - Country:US
Practice Address - Phone:616-477-5618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2024-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI65762225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist