Provider Demographics
NPI:1346900842
Name:BURGESS, JEFFREY A (LPC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:BURGESS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 VERMONT ST STE 150
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-3196
Mailing Address - Country:US
Mailing Address - Phone:785-550-7632
Mailing Address - Fax:
Practice Address - Street 1:1031 VERMONT ST STE 150
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-3196
Practice Address - Country:US
Practice Address - Phone:785-218-0578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-23
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3746101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS3746OtherLICENSE