Basic Information
Provider Information | |||||||||
NPI: | 1225149818 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HUBENKA | ||||||||
FirstName: | JOANN | ||||||||
MiddleName: | JENKINS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW, LMFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JENKINS | ||||||||
OtherFirstName: | JOANN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LMSW, LMFT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 28000 DEQUINDRE RD | ||||||||
Address2: |   | ||||||||
City: | WARREN | ||||||||
State: | MI | ||||||||
PostalCode: | 480922468 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5867530405 | ||||||||
FaxNumber: | 5867530404 | ||||||||
Practice Location | |||||||||
Address1: | 30701 WOODWARD AVE | ||||||||
Address2: | #200 | ||||||||
City: | ROYAL OAK | ||||||||
State: | MI | ||||||||
PostalCode: | 480730987 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2482889333 | ||||||||
FaxNumber: | 2482881362 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801068087 | MI | X |   | Behavioral Health & Social Service Providers | Social Worker |   | 106H00000X | 4101006138 | MI | X |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.