Healthcare Provider Details

I. General information

NPI: 1790272235
Provider Name (Legal Business Name): JACQUELYNN ANN RUBSAM CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

638 BIRD BAY DR E APT 203
VENICE FL
34285-6262
US

IV. Provider business mailing address

638 BIRD BAY DR E APT 203
VENICE FL
34285-6262
US

V. Phone/Fax

Practice location:
  • Phone: 216-513-0824
  • Fax:
Mailing address:
  • Phone: 216-513-0824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11015528
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: