Provider Demographics
NPI:1174612261
Name:HUBKA, JACQUELINE R (MA, CEAP, LPC)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:R
Last Name:HUBKA
Suffix:
Gender:F
Credentials:MA, CEAP, LPC
Other - Prefix:MS
Other - First Name:JACKIE
Other - Middle Name:R
Other - Last Name:HUBKA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, CEAP, LPC
Mailing Address - Street 1:7033 SW MACADAM AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2371
Mailing Address - Country:US
Mailing Address - Phone:503-310-7435
Mailing Address - Fax:
Practice Address - Street 1:7033 SW MACADAM AVE STE 104
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-2371
Practice Address - Country:US
Practice Address - Phone:503-310-7435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1253101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional