Provider Demographics
NPI:1619160546
Name:DUBA, JILL (PHD, LPCC, MFTA)
Entity Type:Individual
Prefix:MR
First Name:JILL
Middle Name:
Last Name:DUBA
Suffix:
Gender:F
Credentials:PHD, LPCC, MFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2877 YEARLING AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-0783
Mailing Address - Country:US
Mailing Address - Phone:270-996-7396
Mailing Address - Fax:
Practice Address - Street 1:1045 ELM ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2513
Practice Address - Country:US
Practice Address - Phone:270-843-1804
Practice Address - Fax:270-843-0154
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0819101YP2500X
KYKY-04-0032106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30604011Medicaid