Provider Demographics
NPI:1689962748
Name:BURKE, JENNIFER KATHLEEN (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:KATHLEEN
Last Name:BURKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:HODGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:4175 S GRAND CANYON DR STE 105
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-7155
Mailing Address - Country:US
Mailing Address - Phone:702-912-4254
Mailing Address - Fax:702-847-7624
Practice Address - Street 1:4175 S GRAND CANYON DR STE 105
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-7155
Practice Address - Country:US
Practice Address - Phone:702-912-4254
Practice Address - Fax:702-847-7624
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV708152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy