Healthcare Provider Details

I. General information

NPI: 1639653462
Provider Name (Legal Business Name): JABE B BURNETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 LAFAYETTE STREET
LIVINGSTON AL
35470
US

IV. Provider business mailing address

PO BOX 1246
LIVINGSTON AL
35470-1246
US

V. Phone/Fax

Practice location:
  • Phone: 205-652-9595
  • Fax: 205-652-5202
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberT37145
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: