Basic Information
Provider Information | |||||||||
NPI: | 1225201536 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FELLOWS | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LICSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 208 FLYNN AVE | ||||||||
Address2: | 3-J | ||||||||
City: | BURLINGTON | ||||||||
State: | VT | ||||||||
PostalCode: | 054015429 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8024886900 | ||||||||
FaxNumber: | 8024886901 | ||||||||
Practice Location | |||||||||
Address1: | 1138 PINE STREET | ||||||||
Address2: | CHILD YOUTH AND FAMILY SERVICES | ||||||||
City: | BURLINGTON | ||||||||
State: | VT | ||||||||
PostalCode: | 05401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8024886600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/08/2008 | ||||||||
LastUpdateDate: | 05/11/2011 | ||||||||
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 | 1041C0700X | 089-0001142 | VT | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 1015570 | 05 | VT |   | MEDICAID |