Basic Information
| Provider Information | |||||||||
| NPI: | 1194933465 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KNIRK | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15645 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891145645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025793272 | ||||||||
| FaxNumber: | 7026674667 | ||||||||
| Practice Location | |||||||||
| Address1: | 4750 W OAKEY BLVD | ||||||||
| Address2: | STE 3A | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891021535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026695944 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2007 | ||||||||
| LastUpdateDate: | 06/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 01068904A | IN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 125-050412 | IL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207R00000X | 125-050412 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2084N0400X | 16409 | NV | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1194933465 | 05 | NV | MEDICAID | 3113866 | 05 | OH | MEDICAID | 201002180 | 05 | IN | MEDICAID |