Provider Demographics
NPI:1932648623
Name:BURDINE, JESSICA NICOLE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:BURDINE
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 1:2202 W BENEDICT ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-2138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26 FATHER JOE MURPHY DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-8663
Practice Address - Country:US
Practice Address - Phone:405-830-2938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No174400000XOther Service ProvidersSpecialist