1972765295 NPI number — JODI R KIRKWOOD

Table of content: JODI R KIRKWOOD (NPI 1972765295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972765295 NPI number — JODI R KIRKWOOD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIRKWOOD
Provider First Name:
JODI
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972765295
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1965
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98507-1965
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-753-7224
Provider Business Mailing Address Fax Number:
360-705-2413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 QUINCE ST NE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98506-4009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-753-7224
Provider Business Practice Location Address Fax Number:
360-705-2413
Provider Enumeration Date:
06/27/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 203259289-98506-0000 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9057852 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8989CU . This is a "REGENCE BLUE SHIELD" identifier . This identifiers is of the category "OTHER".