Provider Demographics
NPI:1376577528
Name:BURGESS-WISE, JESSICA ROSE (LADC)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ROSE
Last Name:BURGESS-WISE
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ROSE
Other - Last Name:BURGESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LADC
Mailing Address - Street 1:40 WRIGHT STREET
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:MA
Mailing Address - Zip Code:01069
Mailing Address - Country:US
Mailing Address - Phone:413-283-7651
Mailing Address - Fax:413-284-5117
Practice Address - Street 1:40 WRIGHT STREET
Practice Address - Street 2:WING MEMORIAL HOSPITAL GRISWOLD CENTER
Practice Address - City:PALMER
Practice Address - State:MA
Practice Address - Zip Code:01069
Practice Address - Country:US
Practice Address - Phone:413-284-5285
Practice Address - Fax:413-284-5384
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA674101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)