Provider Demographics
NPI:1467053322
Name:KIMMERLE, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:KIMMERLE
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 1:409 KETTLE CREEK RD APT 3
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-1977
Mailing Address - Country:US
Mailing Address - Phone:570-575-5136
Mailing Address - Fax:
Practice Address - Street 1:535 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702-4224
Practice Address - Country:US
Practice Address - Phone:732-741-0970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00592100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant