Provider Demographics
NPI:1154858116
Name:BURGESS, JACQUELINE (OD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 DOWNTOWN WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-5407
Mailing Address - Country:US
Mailing Address - Phone:865-545-4592
Mailing Address - Fax:
Practice Address - Street 1:1521 DOWNTOWN WEST BLVD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-5407
Practice Address - Country:US
Practice Address - Phone:865-545-4592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-21
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3452152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty