Provider Demographics
NPI:1043808454
Name:KIMANI, JACQUELYNNE M (PMHNP)
Entity type:Individual
Prefix:
First Name:JACQUELYNNE
Middle Name:M
Last Name:KIMANI
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 JACKSON ST STE 1050
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-2313
Mailing Address - Country:US
Mailing Address - Phone:774-420-8961
Mailing Address - Fax:
Practice Address - Street 1:40 JACKSON ST STE 1050
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-2313
Practice Address - Country:US
Practice Address - Phone:774-420-8961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-02
Last Update Date:2021-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2283682163WP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health