Healthcare Provider Details

I. General information

NPI: 1164789475
Provider Name (Legal Business Name): JANE EMERY ELIASSON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2012
Last Update Date: 04/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1878 MOUNTAIN RD STE 1
STOWE VT
05672-4775
US

IV. Provider business mailing address

1878 MOUNTAIN RD STE 1
STOWE VT
05672-4775
US

V. Phone/Fax

Practice location:
  • Phone: 802-253-2273
  • Fax: 802-254-7754
Mailing address:
  • Phone: 802-253-2273
  • Fax: 802-253-7754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number040-0002298
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: