Provider Demographics
NPI:1972061562
Name:KINSEY, JAIME L
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:L
Last Name:KINSEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4952 W 500 N
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-9017
Mailing Address - Country:US
Mailing Address - Phone:260-330-9628
Mailing Address - Fax:
Practice Address - Street 1:4952 W 500 N
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-9017
Practice Address - Country:US
Practice Address - Phone:260-330-9628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN13005509A124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty