Basic Information
| Provider Information | |||||||||
| NPI: | 1891046363 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COURSER | ||||||||
| FirstName: | JACEY | ||||||||
| MiddleName: | RAENELLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AUD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 905 | ||||||||
| Address2: | |||||||||
| City: | ST JOHNSBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058190905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027488141 | ||||||||
| FaxNumber: | 8027484098 | ||||||||
| Practice Location | |||||||||
| Address1: | 1315 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | ST JOHNSBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058199210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027482984 | ||||||||
| FaxNumber: | 8027481778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2012 | ||||||||
| LastUpdateDate: | 04/19/2017 | ||||||||
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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 | 231H00000X | A615 | NH | N | Speech, Language and Hearing Service Providers | Audiologist | 231H00000X | 8051143 | VT | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 1021087 | 05 | VT | MEDICAID | 3084249 | 05 | NH | MEDICAID |