Healthcare Provider Details

I. General information

NPI: 1437814118
Provider Name (Legal Business Name): MRS. JENNIFER LYNN KUCHUK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2021
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 DEL PRADO BLVD S STE 105
CAPE CORAL FL
33990-3601
US

IV. Provider business mailing address

1003 DEL PRADO BLVD S STE 105
CAPE CORAL FL
33990-3601
US

V. Phone/Fax

Practice location:
  • Phone: 239-293-8308
  • Fax:
Mailing address:
  • Phone: 239-293-8308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH21798
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: