Provider Demographics
NPI:1902590227
Name:BURRUSS- CLARK, JETTANNA
Entity Type:Individual
Prefix:
First Name:JETTANNA
Middle Name:
Last Name:BURRUSS- CLARK
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 1:22 MEADOW PL
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-2924
Mailing Address - Country:US
Mailing Address - Phone:240-810-3929
Mailing Address - Fax:
Practice Address - Street 1:22 MEADOW PL
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-2924
Practice Address - Country:US
Practice Address - Phone:240-810-3952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-08
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor