Provider Demographics
NPI:1063145324
Name:BURKETT, JENNIFER MICHELE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELE
Last Name:BURKETT
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 152
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:AL
Mailing Address - Zip Code:36544-0152
Mailing Address - Country:US
Mailing Address - Phone:662-200-6182
Mailing Address - Fax:
Practice Address - Street 1:9037 INDEPENDENCE AVE STE A2
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-7694
Practice Address - Country:US
Practice Address - Phone:251-459-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5862172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist