MEDICARE: MYNA LAQUISHA BURKS M.S. SLP-CCC

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	235Z00000X	Speech-Language Pathologist	SP4186	CA
2	235Z00000X	Speech-Language Pathologist	S3430	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	S3430	OTHER	MS	MS STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	SP4186	OTHER	CA	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1598968802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYNA LAQUISHA BURKS M.S. SLP-CCC

Provider Business Mailing Address
First Line	:	2500 NORTH STATE STREET
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39216-4500
Country	:	US
Telephone Number	:	601-948-1191
Fax Number	:

Provider Business Practice Location Address
First Line	:	1129 HIGHWAY 35 S STE 2
Second Line	:
City	:	FOREST
State	:	MS
Zip	:	39074-8829
Country	:	US
Telephone Number	:	601-469-1001
Fax Number	:

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

Provider Enumeration Date	:	06/06/2007
Last Update Date	:	10/26/2018

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Directions to “ MYNA LAQUISHA BURKS M.S. SLP-CCC” Practice Location

Language	Start Address	Practice Location

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