Basic Information
| Provider Information | |||||||||
| NPI: | 1306922612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COFFIN | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | WEBSTER | ||||||||
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| Credential: | LICSW, MACP, LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 208 FLYNN AVE | ||||||||
| Address2: | 3-J | ||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054015429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8026580400 | ||||||||
| FaxNumber: | 8026603665 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 FLYNN AVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054015301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024886100 | ||||||||
| FaxNumber: | 8024886901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2006 | ||||||||
| LastUpdateDate: | 06/12/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 000046 | VT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 103T00000X | 047-0000159 | VT | N | Behavioral Health & Social Service Providers | Psychologist | 1041C0700X | 089-0000192 | VT | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1007277 | 05 | VT | MEDICAID |