Healthcare Provider Details

I. General information

NPI: 1902844004
Provider Name (Legal Business Name): KATHLEEN JACKMAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 MAIN ST
MONTPELIER VT
05602-2702
US

IV. Provider business mailing address

PO BOX 547 CENTRAL VERMONT MEDICAL CENTER - FINANCE DEPT
BARRE VT
05641-0547
US

V. Phone/Fax

Practice location:
  • Phone: 802-223-4738
  • Fax: 802-223-6067
Mailing address:
  • Phone: 802-223-4738
  • Fax: 802-223-6067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number101-0026217
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number1010026217
License Number StateVT
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number101.0026217
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: