Provider Demographics
NPI:1124224803
Name:BURGESS, JANICE MARIE
Entity Type:Individual
Prefix:MRS
First Name:JANICE
Middle Name:MARIE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JANICE
Other - Middle Name:MARIE
Other - Last Name:MARTLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 W BRIGGSMORE AVE STE I
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-3839
Mailing Address - Country:US
Mailing Address - Phone:209-526-1440
Mailing Address - Fax:209-526-0908
Practice Address - Street 1:2000 W BRIGGSMORE AVE STE I
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-3839
Practice Address - Country:US
Practice Address - Phone:209-526-1440
Practice Address - Fax:209-526-0908
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional