Provider Demographics
NPI:1740731116
Name:KIMMELL, JACK MCINTYRE
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:MCINTYRE
Last Name:KIMMELL
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 1:1526 E LASALLE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2606
Mailing Address - Country:US
Mailing Address - Phone:574-310-1911
Mailing Address - Fax:
Practice Address - Street 1:1526 EAST LASALLE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617
Practice Address - Country:US
Practice Address - Phone:574-310-1911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39253756072255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer