Provider Demographics
NPI:1972013548
Name:BURGETT, JACQUELINE CHRISTINE (RN/IBCLC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:CHRISTINE
Last Name:BURGETT
Suffix:
Gender:F
Credentials:RN/IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4463 W MANDY LEE CV
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096-7775
Mailing Address - Country:US
Mailing Address - Phone:385-313-8301
Mailing Address - Fax:
Practice Address - Street 1:4463 W MANDY LEE CV
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-7775
Practice Address - Country:US
Practice Address - Phone:385-313-8301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT501107-3102163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant