=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619208238
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JILL L KIRK CSA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2010
-----------------------------------------------------
Last Update Date | 08/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3756 WESTERMAN ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77005-1168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-660-8642
-----------------------------------------------------
Fax | 713-660-0805
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3756 WESTERMAN ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77005-1168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-660-8642
-----------------------------------------------------
Fax | 713-660-0805
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------