Provider Demographics
NPI:1932509924
Name:BUBRICK, JENNIFER CHRISTINE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CHRISTINE
Last Name:BUBRICK
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 1:77 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-2737
Mailing Address - Country:US
Mailing Address - Phone:815-973-8783
Mailing Address - Fax:
Practice Address - Street 1:325 ILLINOIS RT 2
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-9118
Practice Address - Country:US
Practice Address - Phone:815-284-6611
Practice Address - Fax:815-284-2834
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health