Healthcare Provider Details

I. General information

NPI: 1215499249
Provider Name (Legal Business Name): JACQUELYN MICHELLE KUKULSKI DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10240 CALUMET AVE FL 2
MUNSTER IN
46321-4082
US

IV. Provider business mailing address

8558 BROADWAY
MERRILLVILLE IN
46410-7032
US

V. Phone/Fax

Practice location:
  • Phone: 219-922-9150
  • Fax: 219-922-9180
Mailing address:
  • Phone: 219-392-7084
  • Fax: 219-703-6854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.074969
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.157681
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number02007548A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: