Healthcare Provider Details

I. General information

NPI: 1821781410
Provider Name (Legal Business Name): JOANNA HELENE JEROSE MSW, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2023
Last Update Date: 07/10/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 RYE CIR
SOUTH BURLINGTON VT
05403-7632
US

IV. Provider business mailing address

1662 PUMPKIN VILLAGE RD
ENOSBURG FALLS VT
05450-5577
US

V. Phone/Fax

Practice location:
  • Phone: 802-654-7607
  • Fax: 802-654-9155
Mailing address:
  • Phone: 802-782-4701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number151.0127654
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: