Provider Demographics
NPI:1790793859
Name:BURG, JEANNETTE E
Entity Type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:E
Last Name:BURG
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 1:1707 SOUTH BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77098-5419
Mailing Address - Country:US
Mailing Address - Phone:713-526-4997
Mailing Address - Fax:
Practice Address - Street 1:9810 FM 1960 BYPASS RD W
Practice Address - Street 2:# 190
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-3522
Practice Address - Country:US
Practice Address - Phone:281-446-0371
Practice Address - Fax:281-446-4299
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100283225X00000X
TX261QR0400X261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX676650Medicare Oscar/Certification