Basic Information
| Provider Information | |||||||||
| NPI: | 1881822419 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIMBALL | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | RENAE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5700 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049155700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8334314077 | ||||||||
| FaxNumber: | 4137747448 | ||||||||
| Practice Location | |||||||||
| Address1: | 238 NORTHAMPTON ST | ||||||||
| Address2: | EASTHAMPTON HEALTH CENTER | ||||||||
| City: | EASTHAMPTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010271046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135299300 | ||||||||
| FaxNumber: | 4135855491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2009 | ||||||||
| LastUpdateDate: | 04/11/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 255263 | MA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 51632 | CT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 61082 | 01 | MA | HEALTH NEW ENGLAND | OTHER | 023060 | 01 | MA | MBHP | OTHER | J52483 | 01 | MA | BCBS OF MA | OTHER |