Provider Demographics
NPI:1922002732
Name:SUCKUT, JAN (DC)
Entity type:Individual
Prefix:DR
First Name:JAN
Middle Name:
Last Name:SUCKUT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:791 EISENHOWER WAY
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-8361
Mailing Address - Country:US
Mailing Address - Phone:805-813-3987
Mailing Address - Fax:
Practice Address - Street 1:2488 TAPO ST
Practice Address - Street 2:STE 2
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-2492
Practice Address - Country:US
Practice Address - Phone:805-583-0895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22865111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU83595Medicare UPIN
CADC22865Medicare ID - Type Unspecified