Provider Demographics
NPI:1912499633
Name:BURLEY, JENNY ALBROUGH (DPT)
Entity Type:Individual
Prefix:DR
First Name:JENNY
Middle Name:ALBROUGH
Last Name:BURLEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2495
Mailing Address - Country:US
Mailing Address - Phone:248-745-1100
Mailing Address - Fax:248-745-0476
Practice Address - Street 1:1 WILLIAM CARLS DR
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382
Practice Address - Country:US
Practice Address - Phone:248-937-4511
Practice Address - Fax:248-937-4512
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013266225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1912499633Medicaid