Healthcare Provider Details

I. General information

NPI: 1700837747
Provider Name (Legal Business Name): JENNIFER KIMBROUGH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 TRINITY PL
MISHAWAKA IN
46545-5006
US

IV. Provider business mailing address

1540 TRINITY PL
MISHAWAKA IN
46545-5006
US

V. Phone/Fax

Practice location:
  • Phone: 260-415-9051
  • Fax:
Mailing address:
  • Phone: 260-415-9051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number33004912
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: