Provider Demographics
NPI:1275543860
Name:POULIN, JENNIFER A (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:POULIN
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:PO BOX 486
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495
Mailing Address - Country:US
Mailing Address - Phone:802-658-0949
Mailing Address - Fax:802-658-1436
Practice Address - Street 1:21 GREGORY DR
Practice Address - Street 2:SUITE 120
Practice Address - City:SO BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403
Practice Address - Country:US
Practice Address - Phone:802-658-0949
Practice Address - Fax:802-658-1436
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0002746225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN1462Medicaid
VT19701OtherBCBS
VT0226418001OtherCIGNA
VT0226418001OtherCIGNA