Provider Demographics
NPI:1376532416
Name:BURGESS, JENNIFER G (OT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:G
Last Name:BURGESS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 HIGHVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37415-2910
Mailing Address - Country:US
Mailing Address - Phone:423-280-1524
Mailing Address - Fax:423-875-2908
Practice Address - Street 1:509 HIGHVIEW CIR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37415-2910
Practice Address - Country:US
Practice Address - Phone:423-280-1524
Practice Address - Fax:423-875-2908
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOT 02430225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3656354Medicaid
TN3656354Medicare ID - Type Unspecified