Provider Demographics
NPI:1093962276
Name:BURNETT, JOHN EDGAR JR (MPT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:EDGAR
Last Name:BURNETT
Suffix:JR
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-1886
Mailing Address - Country:US
Mailing Address - Phone:417-777-4789
Mailing Address - Fax:
Practice Address - Street 1:509 MEADOWLARK AVE
Practice Address - Street 2:
Practice Address - City:CRANE
Practice Address - State:MO
Practice Address - Zip Code:65633-9317
Practice Address - Country:US
Practice Address - Phone:417-723-5281
Practice Address - Fax:417-723-5443
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004006979225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist