Provider Demographics
NPI:1598270530
Name:BURCH, JODI LYNN
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:LYNN
Last Name:BURCH
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 1:3701 MIRANDA AVE
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-5759
Mailing Address - Country:US
Mailing Address - Phone:307-620-1176
Mailing Address - Fax:
Practice Address - Street 1:201 W LAKEWAY RD STE 200
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-6341
Practice Address - Country:US
Practice Address - Phone:307-682-7885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist