Provider Demographics
NPI:1235265521
Name:JACOBS, KIMBERLEY SHANE
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:SHANE
Last Name:JACOBS
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 1:875 WONDERLAND ROAD SOUTH
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N6K3N1
Mailing Address - Country:CA
Mailing Address - Phone:519-657-4753
Mailing Address - Fax:
Practice Address - Street 1:3481 FALCONBRIDGE HIGHWAY
Practice Address - Street 2:
Practice Address - City:GARSON
Practice Address - State:ONTARIO
Practice Address - Zip Code:P3A1Z6
Practice Address - Country:CA
Practice Address - Phone:705-693-0723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1145401111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor