Provider Demographics
NPI:1407637515
Name:VANKIRK, JERRY (CDCA)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:VANKIRK
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1086 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1396
Mailing Address - Country:US
Mailing Address - Phone:740-446-9129
Mailing Address - Fax:740-446-9021
Practice Address - Street 1:1134 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-2600
Practice Address - Country:US
Practice Address - Phone:740-446-9129
Practice Address - Fax:740-446-9021
Is Sole Proprietor?:No
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.186114101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)