Healthcare Provider Details

I. General information

NPI: 1306922612
Provider Name (Legal Business Name): JONATHAN WEBSTER COFFIN LICSW, MACP, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2006
Last Update Date: 06/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 FLYNN AVE
BURLINGTON VT
05401-5301
US

IV. Provider business mailing address

208 FLYNN AVE 3-J
BURLINGTON VT
05401-5429
US

V. Phone/Fax

Practice location:
  • Phone: 802-488-6100
  • Fax: 802-488-6901
Mailing address:
  • Phone: 802-658-0400
  • Fax: 802-660-3665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number000046
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number047-0000159
License Number StateVT
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089-0000192
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: