Provider Demographics
NPI:1487993432
Name:KABBA, JESTINO K
Entity type:Individual
Prefix:
First Name:JESTINO
Middle Name:K
Last Name:KABBA
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 1:3300 BASS LAKE RD STE 211
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-3065
Mailing Address - Country:US
Mailing Address - Phone:612-225-8107
Mailing Address - Fax:
Practice Address - Street 1:3300 BASS LAKE RD STE 211
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-3065
Practice Address - Country:US
Practice Address - Phone:612-225-8107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-12
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider