Basic Information
| Provider Information | |||||||||
| NPI: | 1609231943 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURGESS | ||||||||
| FirstName: | JENA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BSN, MSN, CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WENANDE | ||||||||
| OtherFirstName: | JENA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | BSN, MSN, CNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 201 N FANELLE AVE | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571031126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059996893 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1417 S CLIFF AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053228630 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2015 | ||||||||
| LastUpdateDate: | 07/27/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | CP001020 | SD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.