Provider Demographics
NPI:1972593515
Name:BURK, JEFFREY A
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:A
Last Name:BURK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2814 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8421
Mailing Address - Country:US
Mailing Address - Phone:309-662-2632
Mailing Address - Fax:309-662-7852
Practice Address - Street 1:2814 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-8421
Practice Address - Country:US
Practice Address - Phone:309-662-2632
Practice Address - Fax:309-662-7852
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTR001962255A2300X
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer