Healthcare Provider Details

I. General information

NPI: 1134160310
Provider Name (Legal Business Name): JASON HERBERT FECHTER LPMA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 HOSPITAL LOOP
BERLIN VT
05602-9105
US

IV. Provider business mailing address

PO BOX 647
MONTPELIER VT
05601-0647
US

V. Phone/Fax

Practice location:
  • Phone: 802-479-4083
  • Fax: 802-476-1476
Mailing address:
  • Phone: 802-479-4083
  • Fax: 802-476-1476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number151.0134181
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number047.0000722
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: