Provider Demographics
NPI:1003238940
Name:BURT, JACQUELYN
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:BURT
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 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-400-8722
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:24530 FALCON PLACE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7665
Practice Address - Country:US
Practice Address - Phone:276-619-0075
Practice Address - Fax:276-619-0077
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27664207Q00000X
VA0101257167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVF907B288Medicare PIN
TN103I087588Medicare PIN