Provider Demographics
NPI:1598968802
Name:BURKS, MYNA LAQUISHA (MS SLP-CCC)
Entity Type:Individual
Prefix:
First Name:MYNA
Middle Name:LAQUISHA
Last Name:BURKS
Suffix:
Gender:F
Credentials:MS SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-948-1191
Mailing Address - Fax:
Practice Address - Street 1:1129 HIGHWAY 35 S STE 2
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-8829
Practice Address - Country:US
Practice Address - Phone:601-469-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP4186235Z00000X
MSS3430235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSS3430OtherMS STATE LICENSE
MS05722005Medicaid
CASP4186OtherSTATE LICENSE NUMBER
MSS3430OtherMS STATE LICENSE
MS302I151441Medicare UPIN