Provider Demographics
NPI:1932523446
Name:BURSON, JACQUELINE (LCPC)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:BURSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4545 CRAIN HWY
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:MD
Mailing Address - Zip Code:20695-3045
Mailing Address - Country:US
Mailing Address - Phone:301-609-6723
Mailing Address - Fax:
Practice Address - Street 1:4545 CRAIN HWY
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:MD
Practice Address - Zip Code:20695-3045
Practice Address - Country:US
Practice Address - Phone:301-609-6723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC4878101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health