Provider Demographics
NPI:1639653462
Name:BURNETT, JABE B
Entity Type:Individual
Prefix:
First Name:JABE
Middle Name:B
Last Name:BURNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1246
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:AL
Mailing Address - Zip Code:35470-1246
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:108 LAFAYETTE STREET
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:AL
Practice Address - Zip Code:35470
Practice Address - Country:US
Practice Address - Phone:205-652-9595
Practice Address - Fax:205-652-5202
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
183700000X
AL183700000X
ALT37145183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician