Provider Demographics
NPI:1477116671
Name:BURNS, JAELAN NICOLE
Entity Type:Individual
Prefix:
First Name:JAELAN
Middle Name:NICOLE
Last Name:BURNS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 W PECAN ST APT 1103
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-5512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:585 W PECAN ST APT 1103
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-5512
Practice Address - Country:US
Practice Address - Phone:281-619-6755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX390200000XMedicaid