Healthcare Provider Details

I. General information

NPI: 1992156442
Provider Name (Legal Business Name): JESSA CARPENTER ADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 VT ROUTE 15
JERICHO VT
05465-4413
US

IV. Provider business mailing address

PO BOX 161
JERICHO VT
05465-0161
US

V. Phone/Fax

Practice location:
  • Phone: 802-745-9603
  • Fax:
Mailing address:
  • Phone: 802-745-9603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number104440
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068.0122339
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: