Provider Demographics
NPI:1487791844
Name:JUBB, LUCAS ANTHONY (IMF)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:ANTHONY
Last Name:JUBB
Suffix:
Gender:M
Credentials:IMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4332 ARAGON WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115
Mailing Address - Country:US
Mailing Address - Phone:619-573-2026
Mailing Address - Fax:
Practice Address - Street 1:2204 NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113
Practice Address - Country:US
Practice Address - Phone:619-515-2355
Practice Address - Fax:619-232-7011
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 48628106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist