=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932703378
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIMBERLY JANKUNAS LCSW PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2020
-----------------------------------------------------
Last Update Date | 11/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 172 OAK LEAF CIR
-----------------------------------------------------
City | GLOVERSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12078-5835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-416-0425
-----------------------------------------------------
Fax | 315-802-7670
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 172 OAK LEAF CIR
-----------------------------------------------------
City | GLOVERSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12078-5835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-416-0425
-----------------------------------------------------
Fax | 315-802-7670
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERVISOR
-----------------------------------------------------
Name | MS. KIMBERLY L JANKUNAS
-----------------------------------------------------
Credential | LCSW-R
-----------------------------------------------------
Telephone | 330-416-0425
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------