1720470933 NPI number — JACKALYNNE BURNS MA, BCBA

Table of content: JACKALYNNE BURNS MA, BCBA (NPI 1720470933)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720470933 NPI number — JACKALYNNE BURNS MA, BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURNS
Provider First Name:
JACKALYNNE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DELONG
Provider Other First Name:
JACKALYNNE
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA, BCBA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720470933
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 623
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33576-0623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-999-0447
Provider Business Mailing Address Fax Number:
352-437-4921

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11820 MUNBURY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DADE CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-999-0447
Provider Business Practice Location Address Fax Number:
352-437-4921
Provider Enumeration Date:
02/25/2015

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: 103K00000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 017556800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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