Provider Demographics
NPI:1932945458
Name:BURGESS, JENNIFER (MA, RMHCI)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:MA, RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1149 BENTLEY RD
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-7116
Mailing Address - Country:US
Mailing Address - Phone:352-318-2976
Mailing Address - Fax:
Practice Address - Street 1:4703 NW 53RD AVE STE A2
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32653-3403
Practice Address - Country:US
Practice Address - Phone:352-332-6131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-03
Last Update Date:2025-03-06
Deactivation Date:2024-09-23
Deactivation Code:
Reactivation Date:2025-03-06
Provider Licenses
StateLicense IDTaxonomies
FLIMH23776101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty