Provider Demographics
NPI:1629789870
Name:BURKS, JENNIFER RENAE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENAE
Last Name:BURKS
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 1:7104 NW ASH AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-4500
Mailing Address - Country:US
Mailing Address - Phone:580-919-7523
Mailing Address - Fax:
Practice Address - Street 1:7104 NW ASH AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-4500
Practice Address - Country:US
Practice Address - Phone:580-919-7523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator