Provider Demographics
NPI:1760847115
Name:BURKE, JESSE MARIE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:JESSE
Middle Name:MARIE
Last Name:BURKE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:JESSE
Other - Middle Name:MARIE
Other - Last Name:KISTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:4847 WEST KISTLER ROAD
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431
Mailing Address - Country:US
Mailing Address - Phone:231-233-1599
Mailing Address - Fax:616-897-5954
Practice Address - Street 1:300 W JOHNSON STREET
Practice Address - Street 2:
Practice Address - City:HART
Practice Address - State:MI
Practice Address - Zip Code:49420
Practice Address - Country:US
Practice Address - Phone:231-873-0586
Practice Address - Fax:616-554-5555
Is Sole Proprietor?:No
Enumeration Date:2015-12-29
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010986621041C0700X
MIL944664104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker