Provider Demographics
NPI:1669498853
Name:JENNIFER FAUNTLEROY, M.D., P.C.
Entity Type:Organization
Organization Name:JENNIFER FAUNTLEROY, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:FAUNTLEROY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-775-1398
Mailing Address - Street 1:11 COURT SQ
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4030
Mailing Address - Country:US
Mailing Address - Phone:802-775-1398
Mailing Address - Fax:802-775-5196
Practice Address - Street 1:11 COURT SQ
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4030
Practice Address - Country:US
Practice Address - Phone:802-775-1398
Practice Address - Fax:802-775-5196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-00095682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN1669Medicaid
VTA58212Medicare UPIN
VTVN3888Medicare ID - Type UnspecifiedMEDICARE GROUP PROV. ID
VT0VN1669Medicaid