MEDICARE: DR. KIMBERLY JACKS AUD

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	231H00000X	Audiologist	AUD004099	GA
2	231H00000X	Audiologist	10161	MN

General Provider Information

NPI Number	:	1689195422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIMBERLY JACKS AUD

Provider Business Mailing Address
First Line	:	NORTHSIDE HOSPITAL MANAGED CARE DEPARTMENT
Second Line	:	1000 JOHNSON FERRY RD NE
City	:	ATLATNA
State	:	GA
Zip	:	30342-3034
Country	:	US
Telephone Number	:	404-851-8097
Fax Number	:	404-250-8010

Provider Business Practice Location Address
First Line	:	5565 BLAINE AVE STE 225
Second Line	:
City	:	INVER GROVE HEIGHTS
State	:	MN
Zip	:	55076-1239
Country	:	US
Telephone Number	:	404-297-4230
Fax Number	:

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

Provider Enumeration Date	:	07/02/2017
Last Update Date	:	01/31/2022

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