Provider Demographics
NPI:1316528565
Name:KIRKSEY, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:KIRKSEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1731 E 120TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059-3051
Mailing Address - Country:US
Mailing Address - Phone:909-646-0916
Mailing Address - Fax:
Practice Address - Street 1:13555 COLUMBUS CT
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-3427
Practice Address - Country:US
Practice Address - Phone:909-646-0916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program