Healthcare Provider Details

I. General information

NPI: 1932509924
Provider Name (Legal Business Name): JENNIFER CHRISTINE BUBRICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2014
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 ILLINOIS RT 2
DIXON IL
61021-9118
US

IV. Provider business mailing address

77 HARRISON AVE
DIXON IL
61021-2737
US

V. Phone/Fax

Practice location:
  • Phone: 815-284-6611
  • Fax: 815-284-2834
Mailing address:
  • Phone: 815-973-8783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: