Provider Demographics
NPI:1669294419
Name:KIMMEL, JESSICA (RDH)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KIMMEL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8240 S BUTTERFLY ST
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:KS
Mailing Address - Zip Code:67026-8577
Mailing Address - Country:US
Mailing Address - Phone:316-648-5418
Mailing Address - Fax:
Practice Address - Street 1:123 N TYLER RD STE 100
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-3726
Practice Address - Country:US
Practice Address - Phone:316-648-5418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13439124Q00000X
235500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist
No124Q00000XDental ProvidersDental Hygienist