Provider Demographics
NPI:1417633777
Name:KUBALUKA, JACQUES
Entity Type:Individual
Prefix:MR
First Name:JACQUES
Middle Name:
Last Name:KUBALUKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 JACKSBORO HWY STE 606
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76114-1662
Mailing Address - Country:US
Mailing Address - Phone:214-587-5763
Mailing Address - Fax:
Practice Address - Street 1:5501 JACKSBORO HWY STE 606
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76114-1662
Practice Address - Country:US
Practice Address - Phone:214-587-5763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-22
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company