Healthcare Provider Details

I. General information

NPI: 1205765047
Provider Name (Legal Business Name): JENNIFER ROSE KIDWELL
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1398 SPERBER RD
EL CENTRO CA
92243-9621
US

IV. Provider business mailing address

1398 SPERBER RD
EL CENTRO CA
92243-9621
US

V. Phone/Fax

Practice location:
  • Phone: 760-312-6580
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number21138
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: