Provider Demographics
NPI:1356376909
Name:LEAVITT, JARED AUSTIN (PAC)
Entity type:Individual
Prefix:MR
First Name:JARED
Middle Name:AUSTIN
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 COLCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1473
Mailing Address - Country:US
Mailing Address - Phone:802-847-1237
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-1237
Practice Address - Fax:802-847-1236
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030842363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant