Healthcare Provider Details

I. General information

NPI: 1548180755
Provider Name (Legal Business Name): JENNIFER EVE KIRKHAM MHS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 BURNSIDE RD
SEBASTOPOL CA
95472-9409
US

IV. Provider business mailing address

4300 BURNSIDE RD
SEBASTOPOL CA
95472-9409
US

V. Phone/Fax

Practice location:
  • Phone: 707-239-4574
  • Fax:
Mailing address:
  • Phone: 707-239-4574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: