Healthcare Provider Details

I. General information

NPI: 1427403104
Provider Name (Legal Business Name): JACQUELYN D KUTA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2016
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 ROCKSIDE RD STE 100
INDEPENDENCE OH
44131-2319
US

IV. Provider business mailing address

6500 ROCKSIDE RD STE 100
INDEPENDENCE OH
44131-2319
US

V. Phone/Fax

Practice location:
  • Phone: 216-674-6400
  • Fax: 216-674-6410
Mailing address:
  • Phone: 216-674-6400
  • Fax: 216-674-6410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6473
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: