MEDICARE: MRS. KIMBALL JANE-MARIE SARGENT MSN, PMHCNS-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	080028	NC
2	364SP0808X	Psychiatric/Mental Health Clinical Nurse Specialist	080028	NC
3	364SP0809X	Adult Psychiatric/Mental Health Clinical Nurse Specialist	0261495-01	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10079	OTHER	NC	BCBS PROVIDER #
2	527619	OTHER	NC	VALUE OPTIONS MHS #
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	232289	OTHER	NC	COMPSYCH CORP. PROV #
5	C 2802004	OTHER	NC	UNITEDAMER.INS.CO. PROV #

General Provider Information

NPI Number	:	1174570808
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBALL JANE-MARIE SARGENT MSN, PMHCNS-BC

Provider Business Mailing Address
First Line	:	7155 SUNSET LAKE RD
Second Line	:
City	:	FUQUAY VARINA
State	:	NC
Zip	:	27526-8638
Country	:	US
Telephone Number	:	919-838-0804
Fax Number	:	919-838-1219

Provider Business Practice Location Address
First Line	:	7155 SUNSET LAKE RD
Second Line	:
City	:	FUQUAY VARINA
State	:	NC
Zip	:	27526-8638
Country	:	US
Telephone Number	:	919-838-0804
Fax Number	:	919-838-1219

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2006
Last Update Date	:	01/13/2019

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