Basic Information
| Provider Information | |||||||||
| NPI: | 1952343840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAHN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1352 TERRACE ST | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494423545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317263582 | ||||||||
| FaxNumber: | 2317226933 | ||||||||
| Practice Location | |||||||||
| Address1: | 1352 TERRACE ST | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494423545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317263582 | ||||||||
| FaxNumber: | 2317226933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 09/14/2010 | ||||||||
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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 | 1041C0700X | 6801002414 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 131410 | 01 | MI | COMPSYCH # | OTHER | P11126278 | 01 | MI | MULTIPLAN # | OTHER | 1036856 | 01 | MI | CIGNA # | OTHER |