Provider Demographics
NPI:1245369503
Name:BURGESS, JENNIFER R (PSYD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:R
Last Name:BURGESS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6612 N RIVERSIDE DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-6663
Mailing Address - Country:US
Mailing Address - Phone:817-559-4045
Mailing Address - Fax:855-811-0590
Practice Address - Street 1:6612 N RIVERSIDE DR
Practice Address - Street 2:SUITE 130
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-6663
Practice Address - Country:US
Practice Address - Phone:817-559-4045
Practice Address - Fax:855-811-0590
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32262103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist