Provider Demographics
NPI:1306437959
Name:BURNETT, JERRELL EVERTON
Entity type:Individual
Prefix:
First Name:JERRELL
Middle Name:EVERTON
Last Name:BURNETT
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 1:12367 HAMBRIGHT RD APT 209
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-7683
Mailing Address - Country:US
Mailing Address - Phone:347-239-3751
Mailing Address - Fax:
Practice Address - Street 1:12367 HAMBRIGHT RD APT 209
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7683
Practice Address - Country:US
Practice Address - Phone:347-239-3751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician