MEDICARE: JEANETTE M BURKUM SAC-IT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	19147	WI

General Provider Information

NPI Number	:	1275387482
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANETTE M BURKUM SAC-IT

Provider Business Mailing Address
First Line	:	204 S ORANGE ST
Second Line	:
City	:	RICHLAND CENTER
State	:	WI
Zip	:	53581-2170
Country	:	US
Telephone Number	:	608-383-1261
Fax Number	:	608-383-1348

Provider Business Practice Location Address
First Line	:	204 S ORANGE ST
Second Line	:
City	:	RICHLAND CENTER
State	:	WI
Zip	:	53581-2170
Country	:	US
Telephone Number	:	608-383-1261
Fax Number	:	608-383-1348

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2024
Last Update Date	:	04/15/2024

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