Provider Demographics
NPI:1447250881
Name:BURGESS, JILLANA G
Entity type:Individual
Prefix:
First Name:JILLANA
Middle Name:G
Last Name:BURGESS
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 1:315 W WASHINGTON AVE
Mailing Address - Street 2:STE A
Mailing Address - City:ARTESIA
Mailing Address - State:NM
Mailing Address - Zip Code:88210-2800
Mailing Address - Country:US
Mailing Address - Phone:505-748-3305
Mailing Address - Fax:505-748-3305
Practice Address - Street 1:315 W WASHINGTON AVE
Practice Address - Street 2:STE A
Practice Address - City:ARTESIA
Practice Address - State:NM
Practice Address - Zip Code:88210-2800
Practice Address - Country:US
Practice Address - Phone:505-748-3305
Practice Address - Fax:505-748-3305
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2016-08-22
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
NM845111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM850327964OtherLOVELACE
NMN8814Medicaid
NM850327964OtherMAIL HANDLERS
NM850327964OtherCIGNA
NM850327964OtherCIMARRON
NEK895OtherBC/BS
NM850327964OtherHEALTHSMART
NM2671213Medicare PIN
NM850327964OtherLOVELACE