Provider Demographics
NPI:1679129621
Name:KIRK, ALEX (PHD)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:KIRK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 CHILD ST
Mailing Address - Street 2:OUTPATIENT BEHAVIORAL HEALTH
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2080 CHILD ST.
Practice Address - Street 2:OUTPATIENT BEHAVIORAL HEALTH
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-8880
Practice Address - Country:US
Practice Address - Phone:904-546-6304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0006280103TC0700X
171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical