Provider Demographics
NPI:1578595542
Name:BURDINE, JANE ROGERS (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:ROGERS
Last Name:BURDINE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:GATE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24251-3526
Mailing Address - Country:US
Mailing Address - Phone:276-386-6118
Mailing Address - Fax:
Practice Address - Street 1:218 SHOEMAKER DR
Practice Address - Street 2:
Practice Address - City:GATE CITY
Practice Address - State:VA
Practice Address - Zip Code:24251-2700
Practice Address - Country:US
Practice Address - Phone:276-386-7002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN612235Z00000X
VA2202001034235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2202001034Medicaid