Healthcare Provider Details

I. General information

NPI: 1568023877
Provider Name (Legal Business Name): JEFFERY BURKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 RUSTIN AVE BLDG 1
RIVERSIDE CA
92507-2498
US

IV. Provider business mailing address

4144 CEDAR ST
RIVERSIDE CA
92501-3445
US

V. Phone/Fax

Practice location:
  • Phone: 951-715-5040
  • Fax:
Mailing address:
  • Phone: 516-622-2584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberAII31190619
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAII31190619
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAII31190619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: