Provider Demographics
NPI:1093990632
Name:JERNIGAN, LINDSAY BENNIGSON (PHD, MA)
Entity Type:Individual
Prefix:DR
First Name:LINDSAY
Middle Name:BENNIGSON
Last Name:JERNIGAN
Suffix:
Gender:F
Credentials:PHD, MA
Other - Prefix:MS
Other - First Name:LINDSAY
Other - Middle Name:ANNE
Other - Last Name:BENNIGSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:185 TILLEY DR
Mailing Address - Street 2:SUITE 14
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-4484
Mailing Address - Country:US
Mailing Address - Phone:802-229-8270
Mailing Address - Fax:802-862-8411
Practice Address - Street 1:185 TILLEY DR
Practice Address - Street 2:SUITE 14
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-4484
Practice Address - Country:US
Practice Address - Phone:802-229-8270
Practice Address - Fax:802-862-8411
Is Sole Proprietor?:No
Enumeration Date:2008-01-02
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048.0056429103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1014583Medicaid
11815987OtherCAQH