Healthcare Provider Details

I. General information

NPI: 1174243281
Provider Name (Legal Business Name): JENNIFER KUKUK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date: 10/20/2022
Reactivation Date: 11/15/2022

III. Provider practice location address

500 E VETERANS ST
TOMAH WI
54660-3105
US

IV. Provider business mailing address

W11421 SPAULDING RD
BLACK RIVER FALLS WI
54615-5616
US

V. Phone/Fax

Practice location:
  • Phone: 608-372-3971
  • Fax: 608-372-1779
Mailing address:
  • Phone: 608-372-3971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number9303
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: