Provider Demographics
NPI:1497793558
Name:BURNEY-JACKSON, BRENDA J (NP)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:J
Last Name:BURNEY-JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 DIVISADERO STREET
Mailing Address - Street 2:SUITE 625, BOX 1821
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-0001
Mailing Address - Country:US
Mailing Address - Phone:415-476-4029
Mailing Address - Fax:415-476-4150
Practice Address - Street 1:2356 SUTTER ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3006
Practice Address - Country:US
Practice Address - Phone:415-885-7788
Practice Address - Fax:415-885-7718
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA250554363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA002505540Medicaid
CA002505540Medicaid
CA002505540Medicare PIN