Provider Demographics
NPI:1457747792
Name:LUEBKER, JESSICA (ATC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LUEBKER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5391 FERRIS AVE
Mailing Address - Street 2:
Mailing Address - City:AVE MARIA
Mailing Address - State:FL
Mailing Address - Zip Code:34142-5046
Mailing Address - Country:US
Mailing Address - Phone:510-846-2209
Mailing Address - Fax:
Practice Address - Street 1:5050 AVE MARIA BLVD
Practice Address - Street 2:
Practice Address - City:AVE MARIA
Practice Address - State:FL
Practice Address - Zip Code:34142-9505
Practice Address - Country:US
Practice Address - Phone:239-304-7865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-14
Last Update Date:2016-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL46362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer