Provider Demographics
NPI:1104023563
Name:KUBENA, JERRY KEITH JR (MD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:KEITH
Last Name:KUBENA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 424
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86430-0424
Mailing Address - Country:US
Mailing Address - Phone:800-562-8663
Mailing Address - Fax:
Practice Address - Street 1:515 28 3/4 RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-5016
Practice Address - Country:US
Practice Address - Phone:970-263-4918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00577612084P0800X
CAA1213732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry