Provider Demographics
NPI:1306221254
Name:TUBARO, JACKIE (BSW/LBSW)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:TUBARO
Suffix:
Gender:F
Credentials:BSW/LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2941 S GULLEY RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3160
Mailing Address - Country:US
Mailing Address - Phone:313-278-3040
Mailing Address - Fax:313-278-8671
Practice Address - Street 1:2941 S GULLEY RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3160
Practice Address - Country:US
Practice Address - Phone:313-278-3040
Practice Address - Fax:313-278-8671
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802062936104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker