Healthcare Provider Details

I. General information

NPI: 1225761331
Provider Name (Legal Business Name): JESSILYN DOLAN RN, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 ROY DR
UNDERHILL VT
05489-9428
US

IV. Provider business mailing address

6 ROY DR
UNDERHILL VT
05489-9428
US

V. Phone/Fax

Practice location:
  • Phone: 802-363-5499
  • Fax:
Mailing address:
  • Phone: 802-363-5499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number164.0001062
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: