Provider Demographics
NPI:1063962991
Name:KULKA, JODI (MED)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:KULKA
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-2105
Mailing Address - Country:US
Mailing Address - Phone:937-578-6126
Mailing Address - Fax:
Practice Address - Street 1:1000 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-2105
Practice Address - Country:US
Practice Address - Phone:937-578-6126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool