Provider Demographics
NPI:1043281827
Name:BURKHALTER, JOHN (JACK) E (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN (JACK)
Middle Name:E
Last Name:BURKHALTER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:E
Other - Last Name:BURKHALTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:633 3RD AVE
Mailing Address - Street 2:BOX 3
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-6706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1275 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-6007
Practice Address - Country:US
Practice Address - Phone:646-888-0040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013892103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P28448Medicare UPIN
VL2861Medicare ID - Type Unspecified