Provider Demographics
NPI:1104115104
Name:BURGESS, JESSICA BROOKE (LMSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:BROOKE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:BROOKE
Other - Last Name:RITTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:805 LEONARD ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1138
Mailing Address - Country:US
Mailing Address - Phone:616-451-2021
Mailing Address - Fax:616-774-1001
Practice Address - Street 1:7475 CEILCREST LN NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-8824
Practice Address - Country:US
Practice Address - Phone:616-299-5847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010881861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical