Healthcare Provider Details

I. General information

NPI: 1124224803
Provider Name (Legal Business Name): MRS. JANICE MARIE BURGESS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS JANICE MARIE MARTLING

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W BRIGGSMORE AVE STE I
MODESTO CA
95350-3839
US

IV. Provider business mailing address

2000 W BRIGGSMORE AVE STE I
MODESTO CA
95350-3839
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-1440
  • Fax: 209-526-0908
Mailing address:
  • Phone: 209-526-1440
  • Fax: 209-526-0908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: