Provider Demographics
NPI:1326608308
Name:KIRK, JENNIFER ANNE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:KIRK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5045 N ROSEPOINT WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-0903
Mailing Address - Country:US
Mailing Address - Phone:619-997-6497
Mailing Address - Fax:
Practice Address - Street 1:5045 N ROSEPOINT WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0903
Practice Address - Country:US
Practice Address - Phone:208-391-7893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-20
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-39555104100000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker