Provider Demographics
NPI:1306235486
Name:KUKESH, JESSICA WRAY
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:WRAY
Last Name:KUKESH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2048 GERBER AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-1321
Mailing Address - Country:US
Mailing Address - Phone:209-324-0462
Mailing Address - Fax:
Practice Address - Street 1:151 N SUNRISE AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2924
Practice Address - Country:US
Practice Address - Phone:916-771-8255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP21667235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty