Provider Demographics
NPI:1942257977
Name:LEGACY, JENNIFER (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LEGACY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1346
Mailing Address - Street 2:
Mailing Address - City:LYNDONVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05851-1346
Mailing Address - Country:US
Mailing Address - Phone:802-626-4224
Mailing Address - Fax:802-626-5042
Practice Address - Street 1:31 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:LYNDONVILLE
Practice Address - State:VT
Practice Address - Zip Code:05851
Practice Address - Country:US
Practice Address - Phone:802-626-4224
Practice Address - Fax:802-626-5042
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-003546174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT65837OtherBC/BS
VT398447OtherMVP
0003546OtherVT MANAGED CARE
VT1011382Medicaid
VT65837OtherBC/BS