Healthcare Provider Details

I. General information

NPI: 1366567125
Provider Name (Legal Business Name): JESSICA ERIN BURLEY RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 W CENTRE AVE
PORTAGE MI
49024-5334
US

IV. Provider business mailing address

22189 SALISBURY DR
MATTAWAN MI
49071-9718
US

V. Phone/Fax

Practice location:
  • Phone: 269-321-0664
  • Fax:
Mailing address:
  • Phone: 269-668-4588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302025357
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: