Provider Demographics
NPI:1063500569
Name:KUZMINSKI, JACQUELYN C (MD)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:C
Last Name:KUZMINSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:CHRISTINE
Other - Last Name:NOHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:9000 W SURA LN
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228-3477
Practice Address - Country:US
Practice Address - Phone:414-246-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1635850208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35113300Medicaid
WI1063500569Medicaid
WI736012036Medicare PIN