=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881186591
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACLYN H BURWELL LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2018
-----------------------------------------------------
Last Update Date | 10/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 192 JOAN DR
-----------------------------------------------------
City | TRAPPE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19426-1957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-403-9135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 192 JOAN DR
-----------------------------------------------------
City | TRAPPE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19426-1957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-403-9135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | P011053
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C012156
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CW023284
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------