Provider Demographics
NPI:1497858278
Name:WISDOM-BEHOUNEK, JENNIFER R (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:WISDOM-BEHOUNEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 PINE ST BLDG 4
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VT
Mailing Address - Zip Code:05443-1043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:61 PINE ST BLDG 4
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VT
Practice Address - Zip Code:05443-1043
Practice Address - Country:US
Practice Address - Phone:573-884-7733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT2006017329207Q00000X
MO2009005696207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine