Healthcare Provider Details

I. General information

NPI: 1376532416
Provider Name (Legal Business Name): JENNIFER G BURGESS OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 HIGHVIEW CIR
CHATTANOOGA TN
37415-2910
US

IV. Provider business mailing address

509 HIGHVIEW CIR
CHATTANOOGA TN
37415-2910
US

V. Phone/Fax

Practice location:
  • Phone: 423-280-1524
  • Fax: 423-875-2908
Mailing address:
  • Phone: 423-280-1524
  • Fax: 423-875-2908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT 02430
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: