Provider Demographics
NPI:1205088150
Name:KULAK, JESSICA LEE (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:KULAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8923 ROAN LN
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-5441
Mailing Address - Country:US
Mailing Address - Phone:859-331-9600
Mailing Address - Fax:
Practice Address - Street 1:133 BARNWOOD DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-2500
Practice Address - Country:US
Practice Address - Phone:859-331-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN10480207Y00000X
KY44925207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology