Healthcare Provider Details

I. General information

NPI: 1770064495
Provider Name (Legal Business Name): JESSICA BOUCHER HURLBERT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 HARMON DR
NORTHFIELD VT
05663-1035
US

IV. Provider business mailing address

51 MARTIN MEADOW RD
PLAINFIELD VT
05667-9424
US

V. Phone/Fax

Practice location:
  • Phone: 802-485-3044
  • Fax:
Mailing address:
  • Phone: 802-585-0881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number104.0127549
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: