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General NPI Number Information
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NPI Number | 1477374379
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Entity Type | Individual
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Provider Name | JACOB EDMONDSON MA
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Gender | Male
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Dates
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Enumeration Date | 10/23/2024
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Last Update Date | 10/23/2024
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Provider Practice Location Address
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Address Line | 149 STATE ST UNIT 6
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City | MONTPELIER
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State | VT
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Zip | 05602-2965
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Country | US
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Telephone | 802-522-8298
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Fax |
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Provider Business Mailing Address
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Address Line | 28 RIDGEWOOD TER
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City | BARRE
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State | VT
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Zip | 05641-9738
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Country | US
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Telephone | 802-522-9211
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State | VT
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