Provider Demographics
NPI:1770011256
Name:BURKETT, JESSICA L (D-PT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:BURKETT
Suffix:
Gender:F
Credentials:D-PT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:WIEGERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:D-PT
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:1630 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-5753
Practice Address - Country:US
Practice Address - Phone:920-430-4700
Practice Address - Fax:920-430-4747
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13814-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist