Provider Demographics
NPI:1164836243
Name:BURSTEIN, JESSICA LENA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LENA
Last Name:BURSTEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LENA
Other - Last Name:BURSTEIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:350 PEE DEE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-4945
Mailing Address - Country:US
Mailing Address - Phone:704-986-1500
Mailing Address - Fax:
Practice Address - Street 1:5700 EXECUTIVE CENTER DR STE 110
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8833
Practice Address - Country:US
Practice Address - Phone:704-525-3255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0111541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical