Provider Demographics
NPI:1487329769
Name:STARK, KIMBERLY JORDAN (MS,CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JORDAN
Last Name:STARK
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 ELLAS POND CV
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-3817
Mailing Address - Country:US
Mailing Address - Phone:901-606-9890
Mailing Address - Fax:
Practice Address - Street 1:1762 N CROSSBERRY CV
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-2449
Practice Address - Country:US
Practice Address - Phone:901-428-3445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000006856235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist