Provider Demographics
NPI:1619026366
Name:BURROUGHS, JON MICHAEL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:MICHAEL
Last Name:BURROUGHS
Suffix:
Gender:M
Credentials:LCSW
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Other - Credentials:
Mailing Address - Street 1:4811 FORTUNES RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-9348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5505 CREEDMOOR RD STE 100
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-6333
Practice Address - Country:US
Practice Address - Phone:919-852-5352
Practice Address - Fax:919-933-1854
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NCC0041341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003440Medicaid