1154639185 NPI number — MS. JEAN T DUKICH CNS-BC

Table of content: MS. JEAN T DUKICH CNS-BC (NPI 1154639185)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154639185 NPI number — MS. JEAN T DUKICH CNS-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUKICH
Provider First Name:
JEAN
Provider Middle Name:
T
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CNS-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154639185
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1897
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67201-1897
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-268-8131
Provider Business Mailing Address Fax Number:
316-291-4788

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
848 N SAINT FRANCIS ST
Provider Second Line Business Practice Location Address:
SUITE 1900
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67214-3841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-268-5881
Provider Business Practice Location Address Fax Number:
316-268-8159
Provider Enumeration Date:
09/24/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 364S00000X , with the licence number:  53-74439 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163W00000X , with the licence number: 34090 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100254720B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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