Healthcare Provider Details

I. General information

NPI: 1134200348
Provider Name (Legal Business Name): JESSICA SUSAN PAYTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 10/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 COURT ST
KEENE NH
03431-1719
US

IV. Provider business mailing address

590 COURT ST
KEENE NH
03431-1719
US

V. Phone/Fax

Practice location:
  • Phone: 603-354-5454
  • Fax: 603-354-6667
Mailing address:
  • Phone: 603-354-5454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number13052
License Number StateNH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier30206528
Identifier TypeMEDICAID
Identifier StateNH
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: