Provider Demographics
NPI:1093186207
Name:BURGESS, JERROD RICHARD (BSW)
Entity Type:Individual
Prefix:MR
First Name:JERROD
Middle Name:RICHARD
Last Name:BURGESS
Suffix:
Gender:M
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3111 ELECTRIC AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-8127
Mailing Address - Country:US
Mailing Address - Phone:810-985-8900
Mailing Address - Fax:
Practice Address - Street 1:3111 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-8127
Practice Address - Country:US
Practice Address - Phone:810-985-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802088745171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator