Provider Demographics
NPI:1174026405
Name:GRIM, KIMBERLY (LSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GRIM
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:502 MCCARTY LN STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-7025
Mailing Address - Country:US
Mailing Address - Phone:740-577-9003
Mailing Address - Fax:740-577-9184
Practice Address - Street 1:502 MCCARTY LN STE 1
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-7025
Practice Address - Country:US
Practice Address - Phone:740-577-9003
Practice Address - Fax:740-577-9184
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.22077921041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2864002Medicaid