Provider Demographics
NPI:1457765307
Name:BURDITT, JACQUELINE (OTA/L)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BURDITT
Suffix:
Gender:F
Credentials:OTA/L
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:SHIELDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTA/L
Mailing Address - Street 1:311 MARLDALE DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-1717
Mailing Address - Country:US
Mailing Address - Phone:302-373-9941
Mailing Address - Fax:
Practice Address - Street 1:311 MARLDALE DR
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-1717
Practice Address - Country:US
Practice Address - Phone:302-373-9941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-19
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEU2-0001873224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant