Healthcare Provider Details

I. General information

NPI: 1023719226
Provider Name (Legal Business Name): JESSICA KUKLO MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5502 CALDWELL MILL RD STE A
BIRMINGHAM AL
35242-4546
US

IV. Provider business mailing address

1810 5TH AVE S
IRONDALE AL
35210-2006
US

V. Phone/Fax

Practice location:
  • Phone: 205-222-6235
  • Fax: 205-431-3412
Mailing address:
  • Phone: 205-222-6235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number04524
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: