Provider Demographics
NPI:1407884414
Name:JES, KIMBERLY RANDOLPH (DC)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:RANDOLPH
Last Name:JES
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15015 S 13TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-6241
Mailing Address - Country:US
Mailing Address - Phone:630-569-0529
Mailing Address - Fax:
Practice Address - Street 1:177 W COTTONWOOD LN
Practice Address - Street 2:#13
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-2552
Practice Address - Country:US
Practice Address - Phone:520-423-2601
Practice Address - Fax:520-876-4599
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7519111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ100358Medicare PIN
AZU87158Medicare UPIN