Provider Demographics
NPI:1972765295
Name:KIRKWOOD, JODI R
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:R
Last Name:KIRKWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1965
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-1965
Mailing Address - Country:US
Mailing Address - Phone:360-753-7224
Mailing Address - Fax:360-705-2413
Practice Address - Street 1:204 QUINCE ST NE
Practice Address - Street 2:SUITE 100
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-4009
Practice Address - Country:US
Practice Address - Phone:360-753-7224
Practice Address - Fax:360-705-2413
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
203259289-98506-0000OtherTRICARE
WA9057852Medicaid
8989CUOtherREGENCE BLUE SHIELD
8989CUOtherREGENCE BLUE SHIELD