Provider Demographics
NPI:1548770522
Name:KIRCHMAN, JIM HAROLD (LADC)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:HAROLD
Last Name:KIRCHMAN
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2480 S COUNTY ROAD 45
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-5113
Mailing Address - Country:US
Mailing Address - Phone:612-454-2130
Mailing Address - Fax:507-451-2705
Practice Address - Street 1:2480 S COUNTY ROAD 45
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-5113
Practice Address - Country:US
Practice Address - Phone:612-454-2130
Practice Address - Fax:507-451-2705
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302919101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC543034150512OtherDRIVER'S LICENSE