Provider Demographics
NPI:1194933465
Name:KNIRK, JESSICA ANN (MD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:ANN
Last Name:KNIRK
Suffix:
Gender:F
Credentials:MD
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 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-579-3272
Mailing Address - Fax:702-667-4667
Practice Address - Street 1:4750 W OAKEY BLVD
Practice Address - Street 2:STE 3A
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1535
Practice Address - Country:US
Practice Address - Phone:702-669-5944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-19
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068904A2084N0400X
IL125-0504122084N0400X, 207R00000X
NV164092084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1194933465Medicaid
OH3113866Medicaid
IN201002180Medicaid
NV1194933465Medicaid
OH3113866Medicaid
OH4314891Medicare PIN