Provider Demographics
NPI:1598066722
Name:NOWLAN, JEFFERY M (ADAC)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:M
Last Name:NOWLAN
Suffix:
Gender:M
Credentials:ADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4347
Mailing Address - Country:US
Mailing Address - Phone:802-864-7423
Mailing Address - Fax:802-660-0576
Practice Address - Street 1:31 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4347
Practice Address - Country:US
Practice Address - Phone:802-864-7423
Practice Address - Fax:802-660-0576
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT104278101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT12165201OtherCAQH