Provider Demographics
NPI:1689195422
Name:JACKS, KIMBERLY (AUD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:JACKS
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:NORTHSIDE HOSPITAL MANAGED CARE DEPARTMENT
Mailing Address - Street 2:1000 JOHNSON FERRY RD NE
Mailing Address - City:ATLATNA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-3034
Mailing Address - Country:US
Mailing Address - Phone:404-851-8097
Mailing Address - Fax:404-250-8010
Practice Address - Street 1:5565 BLAINE AVE STE 225
Practice Address - Street 2:
Practice Address - City:INVER GROVE HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55076-1239
Practice Address - Country:US
Practice Address - Phone:404-297-4230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-02
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAUD004099231H00000X
MN10161231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist