Provider Demographics
NPI:1275387482
Name:BURKUM, JEANETTE M (SAC-IT)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:M
Last Name:BURKUM
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 S ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-2170
Mailing Address - Country:US
Mailing Address - Phone:608-383-1261
Mailing Address - Fax:608-383-1348
Practice Address - Street 1:204 S ORANGE ST
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581-2170
Practice Address - Country:US
Practice Address - Phone:608-383-1261
Practice Address - Fax:608-383-1348
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19147101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)