Provider Demographics
NPI:1497840573
Name:KIMBLE, JERRY LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LYNN
Last Name:KIMBLE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 SOUTH HIGH SCHOOL AVE.
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429
Mailing Address - Country:US
Mailing Address - Phone:601-736-2331
Mailing Address - Fax:601-736-2343
Practice Address - Street 1:262 SOUTH HIGH SCHOOL AVE.
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429
Practice Address - Country:US
Practice Address - Phone:601-736-2331
Practice Address - Fax:601-736-2343
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS402111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121066Medicaid
MS350945412Medicare PIN
MS00121066Medicaid