Provider Demographics
NPI:1649834805
Name:CARRUBA, JENNIFER KRISTEN (LCMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KRISTEN
Last Name:CARRUBA
Suffix:
Gender:F
Credentials:LCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02889-1513
Mailing Address - Country:US
Mailing Address - Phone:401-241-4228
Mailing Address - Fax:401-385-9485
Practice Address - Street 1:2260 FLAT RIVER RD UNIT 9
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:RI
Practice Address - Zip Code:02816-8959
Practice Address - Country:US
Practice Address - Phone:401-385-9485
Practice Address - Fax:401-385-9485
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT01547225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMT01547OtherRI MASSAGE LICENSE