Provider Demographics
NPI:1922755727
Name:KIMBALL, JARED AUSTIN (CDCA)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:AUSTIN
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3944 KARL RD APT A
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43224-2126
Mailing Address - Country:US
Mailing Address - Phone:330-523-8739
Mailing Address - Fax:
Practice Address - Street 1:4998 W BROAD ST STE 104
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-1647
Practice Address - Country:US
Practice Address - Phone:614-754-8051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.179818101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty