Provider Demographics
NPI:1265684617
Name:HART, JENNIFIR BAILES (LCMHC)
Entity Type:Individual
Prefix:
First Name:JENNIFIR
Middle Name:BAILES
Last Name:HART
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:PUTNEY
Mailing Address - State:VT
Mailing Address - Zip Code:05346-0658
Mailing Address - Country:US
Mailing Address - Phone:802-387-2254
Mailing Address - Fax:
Practice Address - Street 1:850 MEADOWBROOK RD
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-2594
Practice Address - Country:US
Practice Address - Phone:802-387-2254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068-0000756101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health