Provider Demographics
NPI:1467049254
Name:KIRK, DAVID JASON (TLMHC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JASON
Last Name:KIRK
Suffix:
Gender:M
Credentials:TLMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 343
Mailing Address - Street 2:
Mailing Address - City:RUTHVEN
Mailing Address - State:IA
Mailing Address - Zip Code:51358-0343
Mailing Address - Country:US
Mailing Address - Phone:712-298-4325
Mailing Address - Fax:
Practice Address - Street 1:1105 CENTER ST
Practice Address - Street 2:
Practice Address - City:RUTHVEN
Practice Address - State:IA
Practice Address - Zip Code:51358-8558
Practice Address - Country:US
Practice Address - Phone:712-298-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA105186101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health