Provider Demographics
NPI:1376093799
Name:BURLESON, JESSICA LEANN (COTA/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEANN
Last Name:BURLESON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5122 NEWBURG RD
Mailing Address - Street 2:
Mailing Address - City:HALEYVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35565-6617
Mailing Address - Country:US
Mailing Address - Phone:205-269-9911
Mailing Address - Fax:
Practice Address - Street 1:251 SUNSET PL
Practice Address - Street 2:
Practice Address - City:GUIN
Practice Address - State:AL
Practice Address - Zip Code:35563-2239
Practice Address - Country:US
Practice Address - Phone:205-468-3331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3087174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist