Provider Demographics
NPI:1598316507
Name:SIBOLD, JEREMY STEWART (ATC)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:STEWART
Last Name:SIBOLD
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 TYLER DR
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452-4639
Mailing Address - Country:US
Mailing Address - Phone:802-316-6379
Mailing Address - Fax:
Practice Address - Street 1:10 TYLER DR
Practice Address - Street 2:
Practice Address - City:ESSEX JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05452-4639
Practice Address - Country:US
Practice Address - Phone:802-316-6379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT104.00001672255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty