Provider Demographics
NPI:1013532159
Name:BURGETT, JENNA NICOLE
Entity type:Individual
Prefix:MISS
First Name:JENNA
Middle Name:NICOLE
Last Name:BURGETT
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 1:32100 TELEGRAPH RD STE 205
Mailing Address - Street 2:
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-2454
Mailing Address - Country:US
Mailing Address - Phone:248-712-4266
Mailing Address - Fax:
Practice Address - Street 1:32100 TELEGRAPH RD STE 205
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-2454
Practice Address - Country:US
Practice Address - Phone:248-712-4266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2025-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0-24-15744106E00000X
156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No156F00000XEye and Vision Services ProvidersTechnician/Technologist