Provider Demographics
NPI:1881200269
Name:BURNETTE, JESSICA A
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:BURNETTE
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 1:104 MAXWELL AVE
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23702-1340
Mailing Address - Country:US
Mailing Address - Phone:252-564-5612
Mailing Address - Fax:
Practice Address - Street 1:104 MAXWELL AVE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23702-1340
Practice Address - Country:US
Practice Address - Phone:252-564-5612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019011564225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist