=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730607623
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA BUMPUS KIRK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2017
-----------------------------------------------------
Last Update Date | 05/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 629 NUCKOLLS RD
-----------------------------------------------------
City | BOLIVAR
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38008-1599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-658-3388
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 629 NUCKOLLS RD
-----------------------------------------------------
City | BOLIVAR
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38008-1599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-658-3388
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 203481
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 23390
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------