Healthcare Provider Details

I. General information

NPI: 1497858278
Provider Name (Legal Business Name): JENNIFER R WISDOM-BEHOUNEK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 PINE ST BLDG 4
BRISTOL VT
05443-1043
US

IV. Provider business mailing address

61 PINE ST BLDG 4
BRISTOL VT
05443-1043
US

V. Phone/Fax

Practice location:
  • Phone: 573-884-7733
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberT2006017329
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2009005696
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: