Provider Demographics
NPI:1821671033
Name:KIRK, JODELLE LYNN (NP)
Entity Type:Individual
Prefix:MS
First Name:JODELLE
Middle Name:LYNN
Last Name:KIRK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:LYNN
Other - Last Name:KIRK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5W MENDENHALL STREET
Mailing Address - Street 2:SUITE 511
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715
Mailing Address - Country:US
Mailing Address - Phone:417-439-3374
Mailing Address - Fax:
Practice Address - Street 1:5W MENDENHALL STREET
Practice Address - Street 2:SUITE 511
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715
Practice Address - Country:US
Practice Address - Phone:417-439-3374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTAPRN-159024171W00000X, 363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No171W00000XOther Service ProvidersContractor
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care