Provider Demographics
NPI:1275792855
Name:BURGESS, JACY L (PT)
Entity Type:Individual
Prefix:
First Name:JACY
Middle Name:L
Last Name:BURGESS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 5TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-3437
Mailing Address - Country:US
Mailing Address - Phone:701-253-4000
Mailing Address - Fax:701-253-4040
Practice Address - Street 1:904 5TH AVE NE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-3437
Practice Address - Country:US
Practice Address - Phone:701-253-4000
Practice Address - Fax:701-253-4040
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1109225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist