Provider Demographics
NPI:1558134585
Name:BURGESS, ANDREW JAMAR
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:JAMAR
Last Name:BURGESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 W 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-4610
Mailing Address - Country:US
Mailing Address - Phone:808-518-8746
Mailing Address - Fax:
Practice Address - Street 1:1190 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-4610
Practice Address - Country:US
Practice Address - Phone:808-518-8746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-01
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-24-4404101YA0400X
ORQMHA-R-5413171M00000X, 101YM0800X
OR111413175T00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program