Healthcare Provider Details

I. General information

NPI: 1174937692
Provider Name (Legal Business Name): DR. JENNIE KUCKERTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2014
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 MILL ST
BELMONT MA
02478-1064
US

IV. Provider business mailing address

3020 CHILDRENS WAY MC 5018
SAN DIEGO CA
92123-4223
US

V. Phone/Fax

Practice location:
  • Phone: 617-855-2962
  • Fax:
Mailing address:
  • Phone: 630-362-3645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number11367
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: