MEDICARE: JERROD BURGAN

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	224Z00000X	Occupational Therapy Assistant

General Provider Information

NPI Number	:	1942791678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERROD BURGAN

Provider Business Mailing Address
First Line	:	1549 E LAS PALMARITAS DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85020-3854
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1549 E LAS PALMARITAS DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85020-3854
Country	:	US
Telephone Number	:	419-612-6364
Fax Number	:

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

Provider Enumeration Date	:	05/30/2018
Last Update Date	:	05/30/2018

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