Healthcare Provider Details

I. General information

NPI: 1518349059
Provider Name (Legal Business Name): JENNIE LEANN KUTSCHKA O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2015
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 COMMERCIAL ST
EMPORIA KS
66801-4006
US

IV. Provider business mailing address

PO BOX 207293
DALLAS TX
75320-4006
US

V. Phone/Fax

Practice location:
  • Phone: 620-343-7120
  • Fax: 620-343-2038
Mailing address:
  • Phone: 636-200-4393
  • Fax: 620-343-2038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2009
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: