Provider Demographics
NPI:1073163200
Name:BURKS, STEVONA JESSICA LOE (M ED, SUDP, INTERN)
Entity type:Individual
Prefix:
First Name:STEVONA
Middle Name:JESSICA LOE
Last Name:BURKS
Suffix:
Gender:F
Credentials:M ED, SUDP, INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4526 FEDERAL AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-2132
Mailing Address - Country:US
Mailing Address - Phone:425-349-6200
Mailing Address - Fax:
Practice Address - Street 1:4526 FEDERAL AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2132
Practice Address - Country:US
Practice Address - Phone:425-349-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP61094387101YA0400X
WACG61460342390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)