Provider Demographics
NPI:1578958294
Name:KOUBA, JADA L (LCPC-C)
Entity Type:Individual
Prefix:
First Name:JADA
Middle Name:L
Last Name:KOUBA
Suffix:
Gender:F
Credentials:LCPC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 BAILEY FARM RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-5808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1321 WASHINGTON AVE
Practice Address - Street 2:SUITE 312
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3636
Practice Address - Country:US
Practice Address - Phone:207-577-6037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL4332101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional