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General NPI Number Information
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NPI Number | 1770064495
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Entity Type | Individual
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Provider Name | JESSICA BOUCHER HURLBERT
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Gender | Female
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Dates
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Enumeration Date | 08/22/2018
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Last Update Date | 08/22/2018
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Provider Practice Location Address
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Address Line | 158 HARMON DR
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City | NORTHFIELD
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State | VT
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Zip | 05663-1035
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Country | US
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Telephone | 802-485-3044
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Fax |
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Provider Business Mailing Address
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Address Line | 51 MARTIN MEADOW RD
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City | PLAINFIELD
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State | VT
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Zip | 05667-9424
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Country | US
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Telephone | 802-585-0881
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 104.0127549
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License Number State | VT
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