Healthcare Provider Details

I. General information

NPI: 1538075965
Provider Name (Legal Business Name): JESSICA RUDEBOCK CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1797 POPPLETON DR
WEST BLOOMFIELD MI
48324-1148
US

IV. Provider business mailing address

3588 PLYMOUTH RD # 393
ANN ARBOR MI
48105-2603
US

V. Phone/Fax

Practice location:
  • Phone: 734-352-3543
  • Fax:
Mailing address:
  • Phone: 734-352-3543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number87531
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: