1063641603 NPI number — MRS. JACQUELIN P BURKE NP

Table of content: MRS. JACQUELIN P BURKE NP (NPI 1063641603)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063641603 NPI number — MRS. JACQUELIN P BURKE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURKE
Provider First Name:
JACQUELIN
Provider Middle Name:
P
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063641603
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
605 N CLEVELAND MASSILLON RD
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
AKRON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44333-2200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-668-6545
Provider Business Mailing Address Fax Number:
330-668-2726

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
605 N CLEVELAND MASSILLON RD
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
AKRON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44333-2200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-668-6545
Provider Business Practice Location Address Fax Number:
330-668-2726
Provider Enumeration Date:
07/03/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LX0001X , with the licence number:  COA10347-NP , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)