Healthcare Provider Details

I. General information

NPI: 1730865841
Provider Name (Legal Business Name): KIMBERLY JAYNE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2023
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OGLETOWN STANTON RD STE 5A43
NEWARK DE
19718-2200
US

IV. Provider business mailing address

555 N DUKE ST
LANCASTER PA
17602-2250
US

V. Phone/Fax

Practice location:
  • Phone: 302-623-0188
  • Fax: 302-733-5640
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0107181
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC1-0029767
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD493326
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: