1215499249 NPI number — JACQUELYN MICHELLE KUKULSKI DO

Table of content: JACQUELYN MICHELLE KUKULSKI DO (NPI 1215499249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215499249 NPI number — JACQUELYN MICHELLE KUKULSKI DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUKULSKI
Provider First Name:
JACQUELYN
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1215499249
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/22/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8558 BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERRILLVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46410-7032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-392-7084
Provider Business Mailing Address Fax Number:
219-703-6854

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10240 CALUMET AVE FL 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MUNSTER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46321-4082
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-922-9150
Provider Business Practice Location Address Fax Number:
219-922-9180
Provider Enumeration Date:
04/01/2019

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: 208000000X , with the licence number:  125.074969 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 036.157681 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 02007548A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300083601 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1103769274 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 390200000X , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 118750300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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