Provider Demographics
NPI:1417714072
Name:BURRIS, JACQUELINE (PTA, MPH)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BURRIS
Suffix:
Gender:F
Credentials:PTA, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 FOXWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28785-6902
Mailing Address - Country:US
Mailing Address - Phone:828-734-5158
Mailing Address - Fax:
Practice Address - Street 1:100 SILVER BLUFF DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NC
Practice Address - Zip Code:28716-6350
Practice Address - Country:US
Practice Address - Phone:828-648-2044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4192225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant