Provider Demographics
NPI:1174063226
Name:BURGESS, JENNIFER (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13334 ROLLIN GLEN RD
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-5131
Mailing Address - Country:US
Mailing Address - Phone:858-231-4523
Mailing Address - Fax:
Practice Address - Street 1:10790 RANCHO BERNARDO RD
Practice Address - Street 2:MAIL DROP 4S-205 DESK 2368
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-5527
Practice Address - Country:US
Practice Address - Phone:858-927-5527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005397363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily