Provider Demographics
NPI:1245581289
Name:KOLUCH, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KOLUCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N11893 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:NECEDAH
Mailing Address - State:WI
Mailing Address - Zip Code:54646-7528
Mailing Address - Country:US
Mailing Address - Phone:608-548-2342
Mailing Address - Fax:
Practice Address - Street 1:N11893 12TH AVE
Practice Address - Street 2:
Practice Address - City:NECEDAH
Practice Address - State:WI
Practice Address - Zip Code:54646-7528
Practice Address - Country:US
Practice Address - Phone:608-548-2342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0014118172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0014118OtherADULT FAMILY HOME LICENSE #0014118