Provider Demographics
NPI:1780647024
Name:JONES-KUBESKA, SUSAN LEE (DO)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEE
Last Name:JONES-KUBESKA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:L
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17191 BOTHELL WAY NE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:LAKE FOREST PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98155-4250
Mailing Address - Country:US
Mailing Address - Phone:206-364-8272
Mailing Address - Fax:206-364-5418
Practice Address - Street 1:17191 BOTHELL WAY NE
Practice Address - Street 2:SUITE 205
Practice Address - City:LAKE FOREST PARK
Practice Address - State:WA
Practice Address - Zip Code:98155-4250
Practice Address - Country:US
Practice Address - Phone:206-364-8272
Practice Address - Fax:206-364-5418
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00002044207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G37862Medicare UPIN