Provider Demographics
NPI:1164789475
Name:ELIASSON, JANE EMERY (PT)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:EMERY
Last Name:ELIASSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1878 MOUNTAIN RD STE 1
Mailing Address - Street 2:
Mailing Address - City:STOWE
Mailing Address - State:VT
Mailing Address - Zip Code:05672-4775
Mailing Address - Country:US
Mailing Address - Phone:802-253-2273
Mailing Address - Fax:802-253-7754
Practice Address - Street 1:1878 MOUNTAIN RD STE 1
Practice Address - Street 2:
Practice Address - City:STOWE
Practice Address - State:VT
Practice Address - Zip Code:05672-4775
Practice Address - Country:US
Practice Address - Phone:802-253-2273
Practice Address - Fax:802-254-7754
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0002298225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist