Provider Demographics
NPI:1003861535
Name:BURGESS, JACQUELYN L
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:L
Last Name:BURGESS
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:SWCMHC, 215 N. MAGNOLIA ST.
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29151-1946
Mailing Address - Country:US
Mailing Address - Phone:803-775-9364
Mailing Address - Fax:803-773-6615
Practice Address - Street 1:SWCMHC LEE CMHC, 817 BROWN ST.
Practice Address - Street 2:
Practice Address - City:BISHOPVILLE
Practice Address - State:SC
Practice Address - Zip Code:29010
Practice Address - Country:US
Practice Address - Phone:803-484-9414
Practice Address - Fax:803-484-4299
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor