Provider Demographics
NPI:1568023877
Name:BURKE, JEFFERY
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
Last Name:BURKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4144 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-3445
Mailing Address - Country:US
Mailing Address - Phone:516-622-2584
Mailing Address - Fax:
Practice Address - Street 1:23119 COTTONWOOD AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-9661
Practice Address - Country:US
Practice Address - Phone:951-413-5130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAII31190619101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)