Provider Demographics
NPI:1760719496
Name:BURTON, JACKIE L (MPT)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:L
Last Name:BURTON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22373 TREETOP CIR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-5349
Mailing Address - Country:US
Mailing Address - Phone:561-391-1693
Mailing Address - Fax:
Practice Address - Street 1:22373 TREETOP CIR
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-5349
Practice Address - Country:US
Practice Address - Phone:561-391-1693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-18
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT16372225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT16372OtherPT LICENSE NUMBER