Provider Demographics
NPI:1033967377
Name:TUBALADO, JERRICA
Entity type:Individual
Prefix:MS
First Name:JERRICA
Middle Name:
Last Name:TUBALADO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3107 KENNEDY BLVD FL 1
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-2378
Mailing Address - Country:US
Mailing Address - Phone:201-866-2800
Mailing Address - Fax:
Practice Address - Street 1:3107 JFK BLVD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047
Practice Address - Country:US
Practice Address - Phone:201-866-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-10
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014253225200000X
NJ40QB00414100225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant