Provider Demographics
NPI:1346882909
Name:BURKETTSIMS, JAINEEN
Entity Type:Individual
Prefix:
First Name:JAINEEN
Middle Name:
Last Name:BURKETTSIMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11005 SPAIN RD NE STE 22
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-1871
Mailing Address - Country:US
Mailing Address - Phone:505-250-8851
Mailing Address - Fax:505-843-8449
Practice Address - Street 1:11005 SPAIN RD NE STE 22
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-1871
Practice Address - Country:US
Practice Address - Phone:505-250-8851
Practice Address - Fax:505-843-8449
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM36873594Medicaid