Healthcare Provider Details

I. General information

NPI: 1669175402
Provider Name (Legal Business Name): JESSEN MECHELL BURK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 REDMOND RD NW
ROME GA
30165-1415
US

IV. Provider business mailing address

1310 BURGER CIR
GADSDEN AL
35903-1204
US

V. Phone/Fax

Practice location:
  • Phone: 706-291-0291
  • Fax:
Mailing address:
  • Phone: 706-767-8354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number103310
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: