Provider Demographics
NPI:1902802556
Name:KIMBALL, JACQUELYN DELOIS (MSN)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:DELOIS
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 BURWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38109-6755
Mailing Address - Country:US
Mailing Address - Phone:901-789-3137
Mailing Address - Fax:
Practice Address - Street 1:1056 E RAINES RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6337
Practice Address - Country:US
Practice Address - Phone:901-271-4900
Practice Address - Fax:901-271-4911
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000010667363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care