Provider Demographics
NPI:1326415951
Name:BURGESS, JACQUELINE RENAE (LM, CPM)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:RENAE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:RENAE
Other - Last Name:CRANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LM, CPM
Mailing Address - Street 1:7693 S. VIRGINIA ST.
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-1114
Mailing Address - Country:US
Mailing Address - Phone:239-699-8718
Mailing Address - Fax:775-418-0430
Practice Address - Street 1:7693 S. VIRGINIA ST.
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-1114
Practice Address - Country:US
Practice Address - Phone:775-480-9241
Practice Address - Fax:775-418-0430
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALM661176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife