Provider Demographics
NPI:1881830495
Name:KIMBALL, JACQUELINE M (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:M
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4148 SEEBER RD
Mailing Address - Street 2:
Mailing Address - City:CANASTOTA
Mailing Address - State:NY
Mailing Address - Zip Code:13032-3100
Mailing Address - Country:US
Mailing Address - Phone:315-264-2278
Mailing Address - Fax:
Practice Address - Street 1:130 E. STATE ST.
Practice Address - Street 2:
Practice Address - City:SHERRILL
Practice Address - State:NY
Practice Address - Zip Code:13461
Practice Address - Country:US
Practice Address - Phone:315-231-5250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-02
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
NY024400-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No252Y00000XAgenciesEarly Intervention Provider Agency