=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588302871
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHON LEE KIRKLAND
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2022
-----------------------------------------------------
Last Update Date | 05/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3940 GRANTS MILL RD
-----------------------------------------------------
City | IRONDALE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35210-1204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-977-1802
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5734 BELMONT PL
-----------------------------------------------------
City | IRONDALE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35210-2155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-977-1802
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 5943
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------