Provider Demographics
NPI:1285140202
Name:LUBECK, JADE
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:LUBECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 E 6TH AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-3590
Mailing Address - Country:US
Mailing Address - Phone:801-971-0446
Mailing Address - Fax:
Practice Address - Street 1:348 E 4500 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-3906
Practice Address - Country:US
Practice Address - Phone:801-971-0446
Practice Address - Fax:801-971-0446
Is Sole Proprietor?:No
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1046281435021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical