Provider Demographics
NPI:1336882372
Name:WEADOCK, JENNIFER (LADC, LCPC, LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WEADOCK
Suffix:
Gender:F
Credentials:LADC, LCPC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 KINGSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:VT
Mailing Address - Zip Code:05468-3175
Mailing Address - Country:US
Mailing Address - Phone:802-585-0230
Mailing Address - Fax:
Practice Address - Street 1:73 MAIN ST APT 27
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-2987
Practice Address - Country:US
Practice Address - Phone:802-585-0230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-64684101YA0400X
MTBBH-LCPC-70407101YM0800X
VT151.0134175101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health