Provider Demographics
NPI:1881983633
Name:BURLESON, JENNIFER RENEE (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEE
Last Name:BURLESON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:VANDEN BOSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:5215 S BROOKMERE ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-5097
Mailing Address - Country:US
Mailing Address - Phone:917-405-5514
Mailing Address - Fax:
Practice Address - Street 1:1116 S WALTON BLVD STE 114
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-6126
Practice Address - Country:US
Practice Address - Phone:479-309-1973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-01
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0788681041C0700X
NJ44SC056971001041C0700X
AR11575-C1041C0700X
NY076703104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker