Provider Demographics
NPI:1902844004
Name:JACKMAN, KATHLEEN (APRN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:JACKMAN
Suffix:
Gender:F
Credentials:APRN
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 547
Mailing Address - Street 2:CENTRAL VERMONT MEDICAL CENTER - FINANCE DEPT
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-0547
Mailing Address - Country:US
Mailing Address - Phone:802-223-4738
Mailing Address - Fax:802-223-6067
Practice Address - Street 1:156 MAIN ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-2702
Practice Address - Country:US
Practice Address - Phone:802-223-4738
Practice Address - Fax:802-223-6067
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0026217163W00000X
VT1010026217208D00000X
VT101.0026217363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009335Medicaid
VT1009335Medicaid
VTNP3959Medicare PIN