Healthcare Provider Details

I. General information

NPI: 1275254518
Provider Name (Legal Business Name): ANDRE JERMAINE EASON JR. LADC, LCMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2022
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 PORTLAND ST
ST JOHNSBURY VT
05819-8635
US

IV. Provider business mailing address

PO BOX 62
EAST HAVEN VT
05837-0062
US

V. Phone/Fax

Practice location:
  • Phone: 802-334-6744
  • Fax:
Mailing address:
  • Phone: 203-721-2931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number151.0134147
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068.0135630
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: