Provider Demographics
NPI:1215499249
Name:KUKULSKI, JACQUELYN MICHELLE (DO)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MICHELLE
Last Name:KUKULSKI
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8558 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7032
Mailing Address - Country:US
Mailing Address - Phone:219-392-7084
Mailing Address - Fax:219-703-6854
Practice Address - Street 1:10240 CALUMET AVE FL 2
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-4082
Practice Address - Country:US
Practice Address - Phone:219-922-9150
Practice Address - Fax:219-922-9180
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.074969208000000X
IL036.157681208000000X
IN02007548A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300083601Medicaid
IN1103769274OtherANTHEM
IL390200000XMedicaid