MEDICARE: JENNIFER L RUBALCADA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	405300000X	Prevention Professional	NA	IN

General Provider Information

NPI Number	:	1457906067
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER L RUBALCADA

Provider Business Mailing Address
First Line	:	1101 W OAKDALE DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46807-1747
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1101 W OAKDALE DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46807-1747
Country	:	US
Telephone Number	:	260-246-0132
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2019
Last Update Date	:	08/09/2019

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Directions to “ JENNIFER L RUBALCADA ” Practice Location

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