Provider Demographics
NPI:1184148371
Name:BURKS, JACLYN
Entity type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:
Last Name:BURKS
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 1:4050 AZURITE ST
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-0481
Mailing Address - Country:US
Mailing Address - Phone:239-405-1514
Mailing Address - Fax:
Practice Address - Street 1:8592 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30350-1865
Practice Address - Country:US
Practice Address - Phone:770-552-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012554225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist