Provider Demographics
NPI:1376171967
Name:BURKETT, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:BURKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8075 GARRISON CT APT A
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80005-2296
Mailing Address - Country:US
Mailing Address - Phone:970-691-0064
Mailing Address - Fax:
Practice Address - Street 1:1715 N WEBER ST STE 90
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-7524
Practice Address - Country:US
Practice Address - Phone:970-691-0064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
COPA.0006518363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program