Provider Demographics
NPI:1093227597
Name:KIMBERLIN, JESSICA MARIE (MS, LICDC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:KIMBERLIN
Suffix:
Gender:F
Credentials:MS, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 N LEAVITT RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:OH
Mailing Address - Zip Code:44001-1131
Mailing Address - Country:US
Mailing Address - Phone:419-370-1120
Mailing Address - Fax:419-557-5179
Practice Address - Street 1:530 N LEAVITT RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:OH
Practice Address - Zip Code:44001-1131
Practice Address - Country:US
Practice Address - Phone:419-370-1120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.161856101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)