Provider Demographics
NPI:1568804268
Name:KIMBRO, JACKIE DOERMANN (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:DOERMANN
Last Name:KIMBRO
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25958 MELROSE LN
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35756-3064
Mailing Address - Country:US
Mailing Address - Phone:256-693-5252
Mailing Address - Fax:855-692-2414
Practice Address - Street 1:25958 MELROSE LN
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35756-3064
Practice Address - Country:US
Practice Address - Phone:256-693-5252
Practice Address - Fax:855-692-2414
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2815235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL164512Medicaid