Healthcare Provider Details

I. General information

NPI: 1336469337
Provider Name (Legal Business Name): JESSICA L MACLEOD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2010
Last Update Date: 12/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 WOODRIDGE DRIVE
BERLIN VT
05602-9516
US

IV. Provider business mailing address

PO BOX 547 ATT: CVMC FINANCE DEPT
BARRE VT
05641-0547
US

V. Phone/Fax

Practice location:
  • Phone: 802-371-4700
  • Fax: 802-371-4720
Mailing address:
  • Phone: 802-371-4700
  • Fax: 802-371-4720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number101-0068303
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: