Provider Demographics
NPI:1972039931
Name:KIMBALL, JACKBARRY
Entity type:Individual
Prefix:
First Name:JACKBARRY
Middle Name:
Last Name:KIMBALL
Suffix:
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 1:2501 COTTONTAIL LN
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-5125
Mailing Address - Country:US
Mailing Address - Phone:732-529-7120
Mailing Address - Fax:
Practice Address - Street 1:397 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-1705
Practice Address - Country:US
Practice Address - Phone:207-747-4929
Practice Address - Fax:888-214-0705
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDL419237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist