Healthcare Provider Details

I. General information

NPI: 1831631092
Provider Name (Legal Business Name): HEATHER JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

861 WILLISTON ROAD STE 8 #1089
SOUTH BURLINGTON VT
05403
US

IV. Provider business mailing address

33 W FRANKLIN ST STE 201
HAGERSTOWN MD
21740-4863
US

V. Phone/Fax

Practice location:
  • Phone: 401-533-3966
  • Fax:
Mailing address:
  • Phone: 401-533-3966
  • Fax: 401-496-9657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: