1437876760 NPI number — MR. JASON NILES KUKAS PMHNP-BC

Table of content: MR. JASON NILES KUKAS PMHNP-BC (NPI 1437876760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437876760 NPI number — MR. JASON NILES KUKAS PMHNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUKAS
Provider First Name:
JASON
Provider Middle Name:
NILES
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PMHNP-BC
Provider Gender Code:
M

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:
1437876760
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
41500 WASHINGTON ST APT E224
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERMUDA DUNES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92203-9516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-989-7608
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
954 W FOOTHILL BLVD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UPLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91786-3782
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-846-4222
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2022

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: 363LP0808X , with the licence number:  95023040 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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