=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629575345
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAIMIE C DIRKS PMHNP-BC, FNP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2018
-----------------------------------------------------
Last Update Date | 01/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1762 HOFFMAN DR STE 101
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80538-4292
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-235-0615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1762 HOFFMAN DR STE 101
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80538-4292
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-235-0615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 112453
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 0103879
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 37741.1750
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 0993371-NP
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------