Provider Demographics
NPI:1912214867
Name:BURCH, JESSICA D (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:D
Last Name:BURCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 W CHAPEL HILL ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-3027
Mailing Address - Country:US
Mailing Address - Phone:919-419-3474
Mailing Address - Fax:919-419-9353
Practice Address - Street 1:1121 W CHAPEL HILL ST
Practice Address - Street 2:SUITE 100
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-3027
Practice Address - Country:US
Practice Address - Phone:919-419-3474
Practice Address - Fax:919-419-9353
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC008046101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0268768Medicaid