Provider Demographics
NPI:1649557653
Name:BURGHY, JESSICA SHAE
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:SHAE
Last Name:BURGHY
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 1:160 WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:BARNESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43713-1451
Mailing Address - Country:US
Mailing Address - Phone:740-619-0058
Mailing Address - Fax:
Practice Address - Street 1:160 WARREN AVE
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43713-1451
Practice Address - Country:US
Practice Address - Phone:740-619-0058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.132329-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse