Healthcare Provider Details

I. General information

NPI: 1073215976
Provider Name (Legal Business Name): VICTORIA ANN JACUK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 W MICHIGAN ST
INDIANAPOLIS IN
46202-5209
US

IV. Provider business mailing address

1120 W MICHIGAN ST
INDIANAPOLIS IN
46202-5209
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-7724
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number02009084A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: