Basic Information
| Provider Information | |||||||||
| NPI: | 1720055304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURNETT | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | HSPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 LINCOLN WAY E | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466013220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742322255 | ||||||||
| FaxNumber: | 5742328968 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 LINCOLN WAY E | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466013220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742322255 | ||||||||
| FaxNumber: | 5742328968 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 12/10/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TB0200X | 20041003A | IN | Y | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
ID Information
| ID | Type | State | Issuer | Description | 148470X | 01 | IN | UNSPECIFIED | OTHER | 200200770A | 05 | IN | MEDICAID |