Healthcare Provider Details

I. General information

NPI: 1164659330
Provider Name (Legal Business Name): JENNIFER S. KUCKUK MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2995 SUB ZERO PKWY
FITCHBURG WI
53719-8801
US

IV. Provider business mailing address

8123 MANSION HILL AVE
MADISON WI
53719-4489
US

V. Phone/Fax

Practice location:
  • Phone: 608-556-2433
  • Fax:
Mailing address:
  • Phone: 920-207-9684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: