Provider Demographics
NPI:1205664109
Name:KIMBLE, JASON R
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:KIMBLE
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 1:11828 TAPP DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-9533
Mailing Address - Country:US
Mailing Address - Phone:317-502-9412
Mailing Address - Fax:
Practice Address - Street 1:120 W MCKENZIE RD STE F
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-1072
Practice Address - Country:US
Practice Address - Phone:317-468-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34010801A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical