Healthcare Provider Details

I. General information

NPI: 1952173098
Provider Name (Legal Business Name): JORDAN GRACE KUCHTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1932 14TH ST
SANTA MONICA CA
90404-4605
US

IV. Provider business mailing address

9612 LUCERNE AVE APT 305
CULVER CITY CA
90232-2926
US

V. Phone/Fax

Practice location:
  • Phone: 310-344-2276
  • Fax:
Mailing address:
  • Phone: 805-558-7434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number18379
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: