Provider Demographics
NPI:1790143139
Name:BURKE, JEANICE (CRNA, MSN)
Entity type:Individual
Prefix:
First Name:JEANICE
Middle Name:
Last Name:BURKE
Suffix:
Gender:F
Credentials:CRNA, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4303 RICHMOND PARK DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1284
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2165 HERSCHEL ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3819
Practice Address - Country:US
Practice Address - Phone:904-603-0848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-31
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRNA1217367500000X
390200000X
FLARNP 9312264367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ193493Medicare PIN