Provider Demographics
NPI:1093161317
Name:BURGESS, JASMIN RACHAEL (MS/EDS)
Entity Type:Individual
Prefix:
First Name:JASMIN
Middle Name:RACHAEL
Last Name:BURGESS
Suffix:
Gender:F
Credentials:MS/EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W THARPE ST
Mailing Address - Street 2:SUITE 7
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-5374
Mailing Address - Country:US
Mailing Address - Phone:850-561-8060
Mailing Address - Fax:850-561-1143
Practice Address - Street 1:971 SW WALNUT ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123
Practice Address - Country:US
Practice Address - Phone:503-640-5297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-05
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health