Provider Demographics
NPI:1205039328
Name:BURDEN, JESSE EDWARD (PTA)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:EDWARD
Last Name:BURDEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 ZIRCON CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1186
Mailing Address - Country:US
Mailing Address - Phone:757-215-6836
Mailing Address - Fax:
Practice Address - Street 1:806 ZIRCON CT
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-1186
Practice Address - Country:US
Practice Address - Phone:757-215-6836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002323225200000X
VA0117005352225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant