Healthcare Provider Details

I. General information

NPI: 1649521212
Provider Name (Legal Business Name): ELIZABETH SUSAN JORDAN-SHOOK M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2012
Last Update Date: 09/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 BLAIR PARK RD STE. 240
WILLISTON VT
05495
US

IV. Provider business mailing address

600 BLAIR PARK RD STE. 240
WILLISTON VT
05495
US

V. Phone/Fax

Practice location:
  • Phone: 802-876-5315
  • Fax: 802-876-6291
Mailing address:
  • Phone: 802-876-5315
  • Fax: 802-876-6291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: