=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164890109
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JARED KUBIK
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2015
-----------------------------------------------------
Last Update Date | 06/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9720 GROUSE RIDGE LN
-----------------------------------------------------
City | LITTLE ELM
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75068-0500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-884-9132
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9720 GROUSE RIDGE LN
-----------------------------------------------------
City | LITTLE ELM
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75068-0500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-884-9132
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1174708
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------