Provider Demographics
NPI:1679997340
Name:BURGOS, JENICA LEIGH
Entity type:Individual
Prefix:MRS
First Name:JENICA
Middle Name:LEIGH
Last Name:BURGOS
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 1:5245 EDMOND ST
Mailing Address - Street 2:APT 105
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-0312
Mailing Address - Country:US
Mailing Address - Phone:209-471-5470
Mailing Address - Fax:
Practice Address - Street 1:6889 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-4687
Practice Address - Country:US
Practice Address - Phone:702-434-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner