Healthcare Provider Details

I. General information

NPI: 1124887534
Provider Name (Legal Business Name): JACK IRVIN KILLMAN PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1048 ASHLEY ST STE 201
BOWLING GREEN KY
42103-2449
US

IV. Provider business mailing address

1048 ASHLEY ST STE 201
BOWLING GREEN KY
42103-2449
US

V. Phone/Fax

Practice location:
  • Phone: 270-205-4585
  • Fax: 270-867-0024
Mailing address:
  • Phone: 270-205-4585
  • Fax: 270-867-0024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number35865
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: