Provider Demographics
NPI:1508223587
Name:BURKE, JENNY KOLESAR (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:KOLESAR
Last Name:BURKE
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7632 HERSCHEL AVE
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-4403
Mailing Address - Country:US
Mailing Address - Phone:619-888-0956
Mailing Address - Fax:
Practice Address - Street 1:7632 HERSCHEL AVE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-4403
Practice Address - Country:US
Practice Address - Phone:619-888-0956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7769174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist