Provider Demographics
NPI:1679244891
Name:BURGE, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BURGE
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 1:4200 MUNSON ST NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718
Mailing Address - Country:US
Mailing Address - Phone:330-915-2907
Mailing Address - Fax:
Practice Address - Street 1:4200 MUNSON ST NW
Practice Address - Street 2:SUITE A
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718
Practice Address - Country:US
Practice Address - Phone:330-915-2907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 171M00000X
OHC.2304818-TRNE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator