Healthcare Provider Details

I. General information

NPI: 1285565788
Provider Name (Legal Business Name): JONATHAN MARCIAL KLOCK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JONATHAN MARCIAL

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 OLD CHAPEL RD.
MIDDLEBURY VT
05753
US

IV. Provider business mailing address

42 ATKINS FARM RD
FERRISBURGH VT
05456-9104
US

V. Phone/Fax

Practice location:
  • Phone: 802-443-3273
  • Fax:
Mailing address:
  • Phone: 802-338-0366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: