Basic Information
| Provider Information | |||||||||
| NPI: | 1437556115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUBBELL | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LSCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1150 N. BROADWAY | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168662000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1122 N TOPEKA ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672142810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168662000 | ||||||||
| FaxNumber: | 3168662084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2014 | ||||||||
| LastUpdateDate: | 12/02/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 9427 | KS | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 201105440B | 05 | KS | MEDICAID | 100098080C | 01 | KS | SED WAIVER | OTHER | 100098080A | 05 | KS | MEDICAID |