Provider Demographics
NPI:1649279977
Name:BURGESS, JENNIFER L (DC)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:BURGESS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S OAK ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARMEL
Mailing Address - State:PA
Mailing Address - Zip Code:17851-2145
Mailing Address - Country:US
Mailing Address - Phone:570-339-4599
Mailing Address - Fax:866-876-8987
Practice Address - Street 1:107 S OAK ST
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:PA
Practice Address - Zip Code:17851-2145
Practice Address - Country:US
Practice Address - Phone:570-339-4599
Practice Address - Fax:866-876-8987
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA007320-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABU451351OtherHIGHMARK
PA50000378OtherCAPITAL BLUE
PA0017362670001Medicaid
PAU73835Medicare UPIN
PA0017362670001Medicaid