Healthcare Provider Details

I. General information

NPI: 1669294419
Provider Name (Legal Business Name): JESSICA KIMMEL RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2024
Last Update Date: 10/31/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 N TYLER RD STE 100
WICHITA KS
67212-3726
US

IV. Provider business mailing address

8240 S BUTTERFLY ST
CLEARWATER KS
67026-8577
US

V. Phone/Fax

Practice location:
  • Phone: 316-648-5418
  • Fax:
Mailing address:
  • Phone: 316-648-5418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number13439
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code235500000X
TaxonomySpeech/Language/Hearing Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: