Healthcare Provider Details

I. General information

NPI: 1902802556
Provider Name (Legal Business Name): JACQUELYN DELOIS KIMBALL MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1056 E RAINES RD
MEMPHIS TN
38116-6337
US

IV. Provider business mailing address

244 BURWOOD DR
MEMPHIS TN
38109-6755
US

V. Phone/Fax

Practice location:
  • Phone: 901-271-4900
  • Fax: 901-271-4911
Mailing address:
  • Phone: 901-789-3137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPN0000010667
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: