Provider Demographics
NPI:1639064900
Name:KIMBROUGH, JACKSON ELLIS (PA)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:ELLIS
Last Name:KIMBROUGH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 SOUTHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA HILLS
Mailing Address - State:AL
Mailing Address - Zip Code:35216-1539
Mailing Address - Country:US
Mailing Address - Phone:205-936-4668
Mailing Address - Fax:
Practice Address - Street 1:2105 SOUTHWOOD RD
Practice Address - Street 2:
Practice Address - City:VESTAVIA HILLS
Practice Address - State:AL
Practice Address - Zip Code:35216-1539
Practice Address - Country:US
Practice Address - Phone:205-936-4668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant