Provider Demographics
NPI:1497119978
Name:VISCO, JACK E (NP)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:E
Last Name:VISCO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:E
Other - Last Name:FITCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:260 CREST RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAINT ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478-9503
Mailing Address - Country:US
Mailing Address - Phone:802-524-8805
Mailing Address - Fax:802-524-8939
Practice Address - Street 1:260 CREST RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-9503
Practice Address - Country:US
Practice Address - Phone:802-524-8805
Practice Address - Fax:802-524-8939
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0119461363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily