=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770398000
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA JOANNE BURLEW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2025
-----------------------------------------------------
Last Update Date | 02/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2638 TWO NOTCH RD # ED
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29204-1454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-936-1550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 529 LIVEBARK LN
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29073-7579
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-207-4544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------