Provider Demographics
NPI:1619990827
Name:ETTER, JEAN (LICSW)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:ETTER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 RIVER ST
Mailing Address - Street 2:C/O NETWORK MANAGEMENT SERVICES
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-2306
Mailing Address - Country:US
Mailing Address - Phone:802-885-5785
Mailing Address - Fax:802-885-2030
Practice Address - Street 1:18 OLD TERRACE
Practice Address - Street 2:THE WINDHAM CENTER
Practice Address - City:BELLOW FALLS
Practice Address - State:VT
Practice Address - Zip Code:05101
Practice Address - Country:US
Practice Address - Phone:802-463-1292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-00007691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN2603Medicaid
NH30420624Medicaid
VTS37002Medicare UPIN
VTOVN2603Medicaid