Healthcare Provider Details

I. General information

NPI: 1902679749
Provider Name (Legal Business Name): JAMAL LIONEL BURGESS M.A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2023
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N PIKE W
SUMTER SC
29153-1906
US

IV. Provider business mailing address

3225 RALEIGH DR APT 31
SUMTER SC
29150-2077
US

V. Phone/Fax

Practice location:
  • Phone: 843-934-4375
  • Fax:
Mailing address:
  • Phone: 843-373-9993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: