Healthcare Provider Details

I. General information

NPI: 1720688278
Provider Name (Legal Business Name): KIMBERLY MICHELLE JACOBS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIMBERLY WALLER

II. Dates (important events)

Enumeration Date: 10/26/2020
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 ENTERPRISE DR STE A
OXFORD MS
38655-2762
US

IV. Provider business mailing address

304 ENTERPRISE DR STE A
OXFORD MS
38655-2762
US

V. Phone/Fax

Practice location:
  • Phone: 662-638-3026
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3491
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3491
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: