Healthcare Provider Details

I. General information

NPI: 1609887892
Provider Name (Legal Business Name): JENIFER BURKETT MA MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 12/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38550 S HIGHWAY 1
GUALALA CA
95445-8592
US

IV. Provider business mailing address

P.O. BOX 6443
SANTA ROSA CA
95403-4157
US

V. Phone/Fax

Practice location:
  • Phone: 707-328-3544
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT30315
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: