Healthcare Provider Details

I. General information

NPI: 1417180928
Provider Name (Legal Business Name): JEANNETTE BURKHARDT PINO PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2009
Last Update Date: 08/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 IRVINE AVE SUITE 111
NEWPORT BEACH CA
92660-3109
US

IV. Provider business mailing address

PO BOX 6526
IRVINE CA
92616-6526
US

V. Phone/Fax

Practice location:
  • Phone: 949-278-3414
  • Fax:
Mailing address:
  • Phone: 949-278-3414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number22668
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number22668
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: