Provider Demographics
NPI:1467198929
Name:BURCH, JENNIFER BROOKE (DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BROOKE
Last Name:BURCH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 RACETRACK RD NE STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-3960
Mailing Address - Country:US
Mailing Address - Phone:850-863-4747
Mailing Address - Fax:
Practice Address - Street 1:405 RACETRACK RD NE STE 101
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-3960
Practice Address - Country:US
Practice Address - Phone:850-863-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11165225100000X
FLPT42272225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist