Provider Demographics
NPI:1194772103
Name:HUBBARD, JACK EDWARD JR (PHD, MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:EDWARD
Last Name:HUBBARD
Suffix:JR
Gender:M
Credentials:PHD, MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:675 E NICOLLET BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-6749
Mailing Address - Country:US
Mailing Address - Phone:952-435-8516
Mailing Address - Fax:763-302-4336
Practice Address - Street 1:675 E NICOLLET BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-6749
Practice Address - Country:US
Practice Address - Phone:952-435-8516
Practice Address - Fax:763-302-4336
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN241572084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0265006OtherPREFERRED ONE
MN0506197OtherMEDICA
MNHP13563OtherHEALTHPARTNERS
MN829007500Medicaid
MN22668OtherAMERICA'S PPO
WI30478600Medicaid
MN07483HUOtherBCBS OF MN
MN100285C029OtherUCARE
MN130004281OtherRAILROAD MEDICARE
MN130000063Medicare ID - Type UnspecifiedMEDICARE
MN0506197OtherMEDICA