Healthcare Provider Details

I. General information

NPI: 1699893156
Provider Name (Legal Business Name): JACQUELINE BURNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 SUMMIT GLEN RD
DAYTON OH
45449-3647
US

IV. Provider business mailing address

2903 ARMEN AVE
DAYTON OH
45432-3701
US

V. Phone/Fax

Practice location:
  • Phone: 937-436-2273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA 02873
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: