Provider Demographics
NPI:1194437806
Name:JUKKA, KENDALL CHRISTINE (NP)
Entity type:Individual
Prefix:
First Name:KENDALL
Middle Name:CHRISTINE
Last Name:JUKKA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 TRIBUTE CENTER DR APT 235
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3226
Mailing Address - Country:US
Mailing Address - Phone:661-644-4561
Mailing Address - Fax:
Practice Address - Street 1:110 KILDAIRE PARK DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-8162
Practice Address - Country:US
Practice Address - Phone:919-235-6466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-14
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95023560363LF0000X
NC5019665363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1194437806Medicaid