Basic Information
| Provider Information | |||||||||
| NPI: | 1578739140 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIPKA | ||||||||
| FirstName: | JAIME | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 905 | ||||||||
| Address2: | |||||||||
| City: | ST JOHNSBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058190905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027489501 | ||||||||
| FaxNumber: | 8027483420 | ||||||||
| Practice Location | |||||||||
| Address1: | 195 INDUSTRIAL PKWY STE 1 | ||||||||
| Address2: | |||||||||
| City: | LYNDONVILLE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058514511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027489501 | ||||||||
| FaxNumber: | 8027483420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2008 | ||||||||
| LastUpdateDate: | 03/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 089-0001216 | VT | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 089.0001216 | VT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 3075319 | 05 | NH | MEDICAID | 1014894 | 05 | VT | MEDICAID |