Healthcare Provider Details

I. General information

NPI: 1376171967
Provider Name (Legal Business Name): JONATHAN BURKETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 01/26/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 N WEBER ST STE 90
COLORADO SPRINGS CO
80907-7524
US

IV. Provider business mailing address

8075 GARRISON CT APT A
ARVADA CO
80005-2296
US

V. Phone/Fax

Practice location:
  • Phone: 970-691-0064
  • Fax:
Mailing address:
  • Phone: 970-691-0064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0006518
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: