Healthcare Provider Details

I. General information

NPI: 1780468868
Provider Name (Legal Business Name): JACQUELINE HANNA BURKE PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 DEFENSE HWY STE 203
ANNAPOLIS MD
21401-8922
US

IV. Provider business mailing address

166 DEFENSE HWY STE 203
ANNAPOLIS MD
21401-8922
US

V. Phone/Fax

Practice location:
  • Phone: 410-684-3806
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAC005788
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberAC005788
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: