Basic Information
Provider Information | |||||||||
NPI: | 1144343054 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BURGOON | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | ROMANS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD, | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 4412 | ||||||||
Address2: |   | ||||||||
City: | BENNINGTON | ||||||||
State: | VT | ||||||||
PostalCode: | 052014412 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8024308355 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 160 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | BENNINGTON | ||||||||
State: | VT | ||||||||
PostalCode: | 052012279 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2106153483 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2007 | ||||||||
LastUpdateDate: | 09/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY28112 | CA | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 106H00000X | 51200 | CA | N |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   | 103TC0700X | 048.0132428 | VT | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.