Provider Demographics
NPI:1437814118
Name:KUCHUK, JENNIFER LYNN
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:KUCHUK
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 1:2015 WILLOW BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-3506
Mailing Address - Country:US
Mailing Address - Phone:239-293-8308
Mailing Address - Fax:
Practice Address - Street 1:2015 WILLOW BRANCH DR
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-3506
Practice Address - Country:US
Practice Address - Phone:239-292-8308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH21798101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health