MEDICARE: DR. JENNIFER R BURGESS PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	32262	TX

General Provider Information

NPI Number	:	1245369503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER R BURGESS PSYD

Provider Business Mailing Address
First Line	:	6612 N RIVERSIDE DR
Second Line	:	SUITE 130
City	:	FORT WORTH
State	:	TX
Zip	:	76137-6663
Country	:	US
Telephone Number	:	817-559-4045
Fax Number	:	855-811-0590

Provider Business Practice Location Address
First Line	:	6612 N RIVERSIDE DR
Second Line	:	SUITE 130
City	:	FORT WORTH
State	:	TX
Zip	:	76137-6663
Country	:	US
Telephone Number	:	817-559-4045
Fax Number	:	855-811-0590

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	05/14/2013

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