Provider Demographics
NPI:1164702379
Name:JAMBA, KRISTIN LEE
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LEE
Last Name:JAMBA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-2522
Mailing Address - Country:US
Mailing Address - Phone:607-729-6206
Mailing Address - Fax:607-729-1858
Practice Address - Street 1:257 MAIN ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-2522
Practice Address - Country:US
Practice Address - Phone:607-729-6206
Practice Address - Fax:607-729-1858
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY092836104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker