Provider Demographics
NPI:1134136963
Name:KIMPTON, JON (PHD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:KIMPTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481A KINGSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-3607
Mailing Address - Country:US
Mailing Address - Phone:401-789-2306
Mailing Address - Fax:401-789-2307
Practice Address - Street 1:481A KINGSTOWN RD
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-3607
Practice Address - Country:US
Practice Address - Phone:401-789-2306
Practice Address - Fax:401-789-2307
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00701103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI408420OtherBLUE CHIP
RIJK31307Medicaid
RIPS00701OtherRI LICENSE PSYCHOLOGY
RI23359-0OtherBLUE CROSS/BLUE SHIELD RI
RI61-59401OtherUNITED BEHAVIORAL HEALTH
RI0500760OtherUNITED HEALTHCARE
RI23359-0OtherBLUE CROSS/BLUE SHIELD RI