Provider Demographics
NPI:1366196958
Name:BURKE, JESSICA A
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:A
Last Name:BURKE
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 1:73973 TWO MILE RD APT 40
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277-4610
Mailing Address - Country:US
Mailing Address - Phone:559-704-5119
Mailing Address - Fax:
Practice Address - Street 1:73973 TWO MILE RD APT 40
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277-4610
Practice Address - Country:US
Practice Address - Phone:559-704-5119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician