Healthcare Provider Details

I. General information

NPI: 1821671033
Provider Name (Legal Business Name): JODELLE LYNN KIRK N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JODI LYNN KIRK

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5W MENDENHALL STREET SUITE 511
BOZEMAN MT
59715
US

IV. Provider business mailing address

5W MENDENHALL STREET SUITE 511
BOZEMAN MT
59715
US

V. Phone/Fax

Practice location:
  • Phone: 417-439-3374
  • Fax:
Mailing address:
  • Phone: 417-439-3374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN-159024
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-159024
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License NumberAPRN-159024
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: