Provider Demographics
NPI:1659730877
Name:SUBA, JASODRA
Entity type:Individual
Prefix:
First Name:JASODRA
Middle Name:
Last Name:SUBA
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 1:3835 N FREEWAY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-1954
Mailing Address - Country:US
Mailing Address - Phone:916-576-7900
Mailing Address - Fax:
Practice Address - Street 1:1572 CITRUS MEDICAL CT
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-4547
Practice Address - Country:US
Practice Address - Phone:855-501-1004
Practice Address - Fax:866-456-9587
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-16
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH13823101YM0800X
FLMH13823101YM0800X
FLMH20684101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health