Provider Demographics
NPI:1558865725
Name:BENOURE, JENNIFER (LP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BENOURE
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:LJUNGVALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LP
Mailing Address - Street 1:208 FLYNN AVE STE 3J
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5420
Mailing Address - Country:US
Mailing Address - Phone:802-488-6920
Mailing Address - Fax:802-488-6919
Practice Address - Street 1:1138 PINE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-5353
Practice Address - Country:US
Practice Address - Phone:802-488-6600
Practice Address - Fax:802-488-6919
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047-0121750103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist