Provider Demographics
NPI:1598262651
Name:KIMBALL, JESSE TAYLOR
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:TAYLOR
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-9540
Mailing Address - Country:US
Mailing Address - Phone:605-680-4478
Mailing Address - Fax:
Practice Address - Street 1:311 N 27TH ST STE 1
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-3213
Practice Address - Country:US
Practice Address - Phone:605-644-9074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1334111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor