Provider Demographics
NPI:1780291450
Name:KIRK, JONATHAN ROBERT (DC)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ROBERT
Last Name:KIRK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:JOHNNY
Other - Middle Name:ROBERT
Other - Last Name:KIRK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:230 N WALNUT LN
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60194-3837
Mailing Address - Country:US
Mailing Address - Phone:847-373-7930
Mailing Address - Fax:
Practice Address - Street 1:863 S PERRYVILLE RD STE 100
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-4328
Practice Address - Country:US
Practice Address - Phone:779-423-2044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor