Provider Demographics
NPI:1881238244
Name:SMITH, KIMBERLY JO (LISW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JO
Last Name:SMITH
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FERTILE
Mailing Address - State:IA
Mailing Address - Zip Code:50434-1031
Mailing Address - Country:US
Mailing Address - Phone:641-529-2165
Mailing Address - Fax:641-424-0783
Practice Address - Street 1:320 N EISENHOWER AVE
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-1521
Practice Address - Country:US
Practice Address - Phone:641-424-2391
Practice Address - Fax:641-424-0783
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-29
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA099698104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty