Healthcare Provider Details

I. General information

NPI: 1841414356
Provider Name (Legal Business Name): JAYME A KUKOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13813 METRO PKWY
FORT MYERS FL
33912-4343
US

IV. Provider business mailing address

PO BOX 7006
FORT MYERS FL
33911-7006
US

V. Phone/Fax

Practice location:
  • Phone: 239-936-1343
  • Fax:
Mailing address:
  • Phone: 239-931-3440
  • Fax: 239-931-3454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND4405
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: