Basic Information
| Provider Information | |||||||||
| NPI: | 1225148224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURCH | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2711 S ROUSE ST STE C&D | ||||||||
| Address2: | |||||||||
| City: | PITTSBURG | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667626620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202311068 | ||||||||
| FaxNumber: | 6202312792 | ||||||||
| Practice Location | |||||||||
| Address1: | 2711 S ROUSE ST STE C&D | ||||||||
| Address2: | |||||||||
| City: | PITTSBURG | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667626620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202311068 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 1369 | KS | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 119895 | 01 | KS | BLUE CROSS BLUE SHIELD | OTHER | 200380730A | 05 | KS | MEDICAID |