=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124887534
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACK IRVIN KILLMAN PMHNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2024
-----------------------------------------------------
Last Update Date | 12/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1048 ASHLEY ST STE 201
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42103-2449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-205-4585
-----------------------------------------------------
Fax | 270-867-0024
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1048 ASHLEY ST STE 201
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42103-2449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-205-4585
-----------------------------------------------------
Fax | 270-867-0024
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 35865
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------