Provider Demographics
NPI:1366567125
Name:BURLEY, JESSICA ERIN (RPH)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:ERIN
Last Name:BURLEY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22189 SALISBURY DR
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-9718
Mailing Address - Country:US
Mailing Address - Phone:269-668-4588
Mailing Address - Fax:
Practice Address - Street 1:1950 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5334
Practice Address - Country:US
Practice Address - Phone:269-321-0664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025357183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist