Provider Demographics
NPI:1487452314
Name:BURGOS BLAND, JESSICA MARIE
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:MARIE
Last Name:BURGOS BLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3211 GLOVER DR
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-8963
Mailing Address - Country:US
Mailing Address - Phone:440-645-2906
Mailing Address - Fax:
Practice Address - Street 1:9083 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6462
Practice Address - Country:US
Practice Address - Phone:440-255-0678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-05
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.006098175T00000X
OHCDCA.192522101YA0400X
261QR0405X, 276400000X, 324500000X, 101YA0400X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5874OtherHEALTH PARTNERS
OH568946544OtherBCBS
DC236Medicaid