Healthcare Provider Details

I. General information

NPI: 1295020485
Provider Name (Legal Business Name): JORDAN CHAUSSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 06/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 MAHAN ST
LEBANON NH
03766-1315
US

IV. Provider business mailing address

PO BOX 334
LEBANON NH
03766-0334
US

V. Phone/Fax

Practice location:
  • Phone: 603-443-9639
  • Fax: 603-443-9659
Mailing address:
  • Phone: 603-443-9639
  • Fax: 603-443-9659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number647013
License Number StateNH

VIII. Authorized Official

Name: MS. THERESA ROSE CHAUSSE
Title or Position: PRACTICE OWNER
Credential: AAC
Phone: 603-443-9639