Provider Demographics
NPI:1275913626
Name:JACKIE BURGESS MIDWIFERY
Entity Type:Organization
Organization Name:JACKIE BURGESS MIDWIFERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MIDWIFE
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:R
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:LM
Authorized Official - Phone:239-699-8718
Mailing Address - Street 1:335 LEAWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34104-4162
Mailing Address - Country:US
Mailing Address - Phone:239-699-8718
Mailing Address - Fax:
Practice Address - Street 1:335 LEAWOOD CIR
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34104-4162
Practice Address - Country:US
Practice Address - Phone:239-699-8718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-01
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMW304305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service