Healthcare Provider Details

I. General information

NPI: 1275156903
Provider Name (Legal Business Name): JESSICA E LUBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2020
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 WESTMINSTER PL
OLD TAPPAN NJ
07675-6863
US

IV. Provider business mailing address

20 WESTMINSTER PL
OLD TAPPAN NJ
07675-6863
US

V. Phone/Fax

Practice location:
  • Phone: 201-663-0598
  • Fax:
Mailing address:
  • Phone: 201-663-0598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number031282
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: