Provider Demographics
NPI:1922615004
Name:KIMMEL, JACLYN R (LPC)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:R
Last Name:KIMMEL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 E HIGHLAND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4833
Mailing Address - Country:US
Mailing Address - Phone:480-712-8201
Mailing Address - Fax:480-522-1121
Practice Address - Street 1:2211 E HIGHLAND AVE STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4833
Practice Address - Country:US
Practice Address - Phone:480-712-8201
Practice Address - Fax:480-522-1121
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-17563101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional