Provider Demographics
NPI:1548905821
Name:KUKLA, JANA
Entity type:Individual
Prefix:
First Name:JANA
Middle Name:
Last Name:KUKLA
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 1:14786 FAIRVILLA DR
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-3005
Mailing Address - Country:US
Mailing Address - Phone:503-290-9245
Mailing Address - Fax:
Practice Address - Street 1:14786 FAIRVILLA DR
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-3005
Practice Address - Country:US
Practice Address - Phone:503-290-9245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program