Provider Demographics
NPI:1689310153
Name:KIVETT-KIMBRO, JERRY DAVID
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:DAVID
Last Name:KIVETT-KIMBRO
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 1:21 CRAYTON PARK DR
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28803-0395
Mailing Address - Country:US
Mailing Address - Phone:904-534-2359
Mailing Address - Fax:
Practice Address - Street 1:1100 TUNNEL RD
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28805-2576
Practice Address - Country:US
Practice Address - Phone:904-534-2359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0138011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical