Provider Demographics
NPI:1679768758
Name:TOBON, JENIFFER (ARNP)
Entity Type:Individual
Prefix:
First Name:JENIFFER
Middle Name:
Last Name:TOBON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 S CRAFTSBURY RD
Mailing Address - Street 2:
Mailing Address - City:CRAFTSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05826-9002
Mailing Address - Country:US
Mailing Address - Phone:206-303-0094
Mailing Address - Fax:
Practice Address - Street 1:1 NATIONAL LIFE DR
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05604-9516
Practice Address - Country:US
Practice Address - Phone:802-229-7515
Practice Address - Fax:802-229-7518
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101.0134154363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT101.0134154OtherSTATE LICENSE
WA9653841Medicaid