Provider Demographics
NPI:1609952068
Name:BURKETT, JODY CHARLENE (SLP)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:CHARLENE
Last Name:BURKETT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1379 BELLSMITH DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-0918
Mailing Address - Country:US
Mailing Address - Phone:770-296-9221
Mailing Address - Fax:
Practice Address - Street 1:1379 BELLSMITH DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-0918
Practice Address - Country:US
Practice Address - Phone:770-296-9221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-28
Last Update Date:2013-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13603235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist