Healthcare Provider Details

I. General information

NPI: 1043114341
Provider Name (Legal Business Name): JACK BURKES LSP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 CIRCLEVILLE AVE
ASHVILLE OH
43103-9638
US

IV. Provider business mailing address

4368 BENNINGTON POND DR
GROVEPORT OH
43125-8905
US

V. Phone/Fax

Practice location:
  • Phone: 740-983-5000
  • Fax:
Mailing address:
  • Phone: 567-230-4375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLSP.03273
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: