Basic Information
Provider Information | |||||||||
NPI: | 1902844004 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACKMAN | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 547 | ||||||||
Address2: | CENTRAL VERMONT MEDICAL CENTER - FINANCE DEPT | ||||||||
City: | BARRE | ||||||||
State: | VT | ||||||||
PostalCode: | 056410547 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8022234738 | ||||||||
FaxNumber: | 8022236067 | ||||||||
Practice Location | |||||||||
Address1: | 156 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | MONTPELIER | ||||||||
State: | VT | ||||||||
PostalCode: | 056022702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8022234738 | ||||||||
FaxNumber: | 8022236067 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2006 | ||||||||
LastUpdateDate: | 12/04/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 101-0026217 | VT | N |   | Nursing Service Providers | Registered Nurse |   | 208D00000X | 1010026217 | VT | N |   | Allopathic & Osteopathic Physicians | General Practice |   | 363LF0000X | 101.0026217 | VT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 1009335 | 05 | VT |   | MEDICAID |