Healthcare Provider Details

I. General information

NPI: 1467027300
Provider Name (Legal Business Name): JENNA MICHELE KIMMINAU LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6910 N MAIN ST UNIT 52
GRANGER IN
46530-8412
US

IV. Provider business mailing address

6910 N MAIN ST UNIT 52
GRANGER IN
46530-8412
US

V. Phone/Fax

Practice location:
  • Phone: 574-231-6766
  • Fax: 833-249-2411
Mailing address:
  • Phone: 574-231-6766
  • Fax: 833-249-2411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34012832A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: