=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811244775
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSAMY KAYE BURCH MOTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2012
-----------------------------------------------------
Last Update Date | 08/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4614 84TH ST
-----------------------------------------------------
City | URBANDALE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50322-1089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-270-6838
-----------------------------------------------------
Fax | 515-270-8051
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3801 OLD BRUCEVILLE RD
-----------------------------------------------------
City | VINCENNES
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47591-3889
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-886-4677
-----------------------------------------------------
Fax | 812-886-4678
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 002060
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------