Provider Demographics
NPI:1194283473
Name:KIMBROUGH, JOHN WESLEY JR
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WESLEY
Last Name:KIMBROUGH
Suffix:JR
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 1:2351 CARDINAL LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-3743
Mailing Address - Country:US
Mailing Address - Phone:858-573-2227
Mailing Address - Fax:
Practice Address - Street 1:5650 MOUNT ACKERLY DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-4016
Practice Address - Country:US
Practice Address - Phone:858-496-8205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health