Provider Demographics
NPI:1144525619
Name:JAYNES, SUSAN LUCILLE (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LUCILLE
Last Name:JAYNES
Suffix:
Gender:F
Credentials:NP
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 102
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:VT
Mailing Address - Zip Code:05444-0102
Mailing Address - Country:US
Mailing Address - Phone:802-644-5114
Mailing Address - Fax:802-644-5573
Practice Address - Street 1:272 NO MAIN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:VT
Practice Address - Zip Code:05444-0102
Practice Address - Country:US
Practice Address - Phone:802-644-5114
Practice Address - Fax:802-644-5573
Is Sole Proprietor?:No
Enumeration Date:2011-01-14
Last Update Date:2011-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101 0074099363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner