Provider Demographics
NPI:1073283438
Name:BURKS, JAQUALA
Entity Type:Individual
Prefix:
First Name:JAQUALA
Middle Name:
Last Name:BURKS
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 1:3121 N 86TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3710
Mailing Address - Country:US
Mailing Address - Phone:414-544-9785
Mailing Address - Fax:
Practice Address - Street 1:3121 N 86TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-3710
Practice Address - Country:US
Practice Address - Phone:414-544-9785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2022-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI352250OtherLICENSE NUMBER