Provider Demographics
NPI:1881080414
Name:JEROME, KATHERINE
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:JEROME
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 CROSIER RD
Mailing Address - Street 2:
Mailing Address - City:SHAFTSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05262-9513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:77 S MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:WATERBURY
Practice Address - State:VT
Practice Address - Zip Code:05676-1555
Practice Address - Country:US
Practice Address - Phone:802-244-6366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016.01196722122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist