Provider Demographics
NPI:1750702601
Name:BURK, JARETTA
Entity type:Individual
Prefix:
First Name:JARETTA
Middle Name:
Last Name:BURK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 SUDDERTH DR
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-6119
Mailing Address - Country:US
Mailing Address - Phone:575-257-2368
Mailing Address - Fax:575-257-2141
Practice Address - Street 1:2002 SUDDERTH DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6119
Practice Address - Country:US
Practice Address - Phone:575-257-2368
Practice Address - Fax:575-257-2141
Is Sole Proprietor?:No
Enumeration Date:2013-12-19
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOT3682225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM850441031Medicaid