Provider Demographics
NPI:1710430541
Name:BURDINE, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BURDINE
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 1:268 COUNTY ROAD 1856
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:TX
Mailing Address - Zip Code:76431-3448
Mailing Address - Country:US
Mailing Address - Phone:940-255-1579
Mailing Address - Fax:
Practice Address - Street 1:268 COUNTY ROAD 1856
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:TX
Practice Address - Zip Code:76431-3448
Practice Address - Country:US
Practice Address - Phone:940-255-1579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111498235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111408402Medicaid
TX111408402Medicaid