Provider Demographics
NPI:1659860161
Name:BURKS, JENNIFER ALISE FORTE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ALISE FORTE
Last Name:BURKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ALISE
Other - Last Name:VAN ZANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8815 S TACOMA WAY STE 122
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-7011
Mailing Address - Country:US
Mailing Address - Phone:253-682-0320
Mailing Address - Fax:253-582-2901
Practice Address - Street 1:8815 S TACOMA WAY STE 122
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-7011
Practice Address - Country:US
Practice Address - Phone:253-682-0320
Practice Address - Fax:253-582-2901
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst