Healthcare Provider Details

I. General information

NPI: 1699817536
Provider Name (Legal Business Name): JESSICA KIRK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 CENTER ST STE 1N
MOBILE AL
36604-1512
US

IV. Provider business mailing address

PO BOX 40480
MOBILE AL
36640-0480
US

V. Phone/Fax

Practice location:
  • Phone: 251-410-5437
  • Fax: 251-434-3802
Mailing address:
  • Phone: 251-410-5437
  • Fax: 251-434-3802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number29020
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: