Healthcare Provider Details

I. General information

NPI: 1942913538
Provider Name (Legal Business Name): JACK BURK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2022
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7041 20TH AVE
CENTERVILLE MN
55038-9737
US

IV. Provider business mailing address

3808 HEATHER DR
EAGAN MN
55122-1623
US

V. Phone/Fax

Practice location:
  • Phone: 612-924-3807
  • Fax:
Mailing address:
  • Phone: 952-652-1693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: