Provider Demographics
NPI:1477374379
Name:EDMONDSON, JACOB (MA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:EDMONDSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 RIDGEWOOD TER
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-9738
Mailing Address - Country:US
Mailing Address - Phone:802-522-9211
Mailing Address - Fax:
Practice Address - Street 1:149 STATE ST UNIT 6
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-2965
Practice Address - Country:US
Practice Address - Phone:802-522-8298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health