Provider Demographics
NPI:1487665410
Name:KIRKMAN, JASON (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:KIRKMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 RIVER DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437
Mailing Address - Country:US
Mailing Address - Phone:707-961-4631
Mailing Address - Fax:707-964-1192
Practice Address - Street 1:721 RIVER DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437
Practice Address - Country:US
Practice Address - Phone:707-961-4631
Practice Address - Fax:707-964-1192
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG47142207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G471420OtherMEDI-CAL
CA00G471420Medicare ID - Type Unspecified
CAA50608Medicare UPIN