Provider Demographics
NPI:1194780619
Name:HUBBARD, JENNIFER BARBARA (LAT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BARBARA
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:BARBARA
Other - Last Name:BLODGETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT
Mailing Address - Street 1:S17W32494 US HIGHWAY 18
Mailing Address - Street 2:UNIT D
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-3366
Mailing Address - Country:US
Mailing Address - Phone:920-217-6531
Mailing Address - Fax:
Practice Address - Street 1:S17W32494 US HIGHWAY 18
Practice Address - Street 2:UNIT D
Practice Address - City:DELAFIELD
Practice Address - State:WI
Practice Address - Zip Code:53018-3366
Practice Address - Country:US
Practice Address - Phone:920-217-6531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI719-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer