Healthcare Provider Details

I. General information

NPI: 1477277523
Provider Name (Legal Business Name): COURTNEY JEWEL BURGESS MAT, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E FAIRVIEW AVE # 461
MONTGOMERY AL
36106-2114
US

IV. Provider business mailing address

1504 PECAN VALLEY DR
MCKINNEY TX
75072-8323
US

V. Phone/Fax

Practice location:
  • Phone: 469-525-5710
  • Fax:
Mailing address:
  • Phone: 469-525-5710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberAT9476
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: