Provider Demographics
NPI:1184932410
Name:DUBOSE, JARA (PT)
Entity type:Individual
Prefix:
First Name:JARA
Middle Name:
Last Name:DUBOSE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2431 S LOOP 289
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-1519
Mailing Address - Country:US
Mailing Address - Phone:806-771-8008
Mailing Address - Fax:806-771-8009
Practice Address - Street 1:2431 S LOOP 289
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-1519
Practice Address - Country:US
Practice Address - Phone:806-771-8008
Practice Address - Fax:806-771-8009
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPT1115020225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX540044100OtherFIRSTCARE
TX220122001Medicaid
TX849T44OtherBLUE CROSS BLUE SHIELD
TXP01108866OtherMEDICARE RAILROAD
TX220122002Medicaid
TX220122001Medicaid