Provider Demographics
NPI:1437967460
Name:POLUBINSKY, JESSICA EILEEN (LMHC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:EILEEN
Last Name:POLUBINSKY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:EILEEN
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1129 RIVERMET AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4232
Mailing Address - Country:US
Mailing Address - Phone:260-602-1069
Mailing Address - Fax:
Practice Address - Street 1:3702 RUPP DR STE 5
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4526
Practice Address - Country:US
Practice Address - Phone:260-615-3360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-23
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39003405A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health