Provider Demographics
NPI:1316999030
Name:JAMES, KIMBERLY JEANINE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JEANINE
Last Name:JAMES
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:JAMES-FETTERER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3268 S 28TH ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-8619
Mailing Address - Country:US
Mailing Address - Phone:219-608-4423
Mailing Address - Fax:
Practice Address - Street 1:11 N 400 W
Practice Address - Street 2:
Practice Address - City:LAPORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-7908
Practice Address - Country:US
Practice Address - Phone:219-324-7955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22002444A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200198700Medicaid
IN200718440AOtherFIRST STEPS PROVIDER #