Provider Demographics
NPI:1831519776
Name:KIMPAN, JENNIFER (LICDC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KIMPAN
Suffix:
Gender:F
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 750101
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45475-0101
Mailing Address - Country:US
Mailing Address - Phone:937-672-8400
Mailing Address - Fax:
Practice Address - Street 1:8002 MCEWEN RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45458-2033
Practice Address - Country:US
Practice Address - Phone:937-672-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-18
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
OH131072101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)