Healthcare Provider Details

I. General information

NPI: 1346792843
Provider Name (Legal Business Name): JACQUIN BURNS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2016
Last Update Date: 07/24/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27TH SPECIAL OPERATIONS MEDICAL GROUP 224 W D.L. INGRAM AVENUE, BLDG. 1408
CANNON AFB NM
88103-5159
US

IV. Provider business mailing address

122 COCHRAN AVE E BLDG 575
CANNON AFB NM
88103-5159
US

V. Phone/Fax

Practice location:
  • Phone: 575-268-9504
  • Fax:
Mailing address:
  • Phone: 575-268-9504
  • Fax: 575-763-0041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-09291
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: