Provider Demographics
NPI:1225201536
Name:FELLOWS, JENNIFER C (LICSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:FELLOWS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:291 PILLSBURY LN
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-8728
Mailing Address - Country:US
Mailing Address - Phone:802-233-7420
Mailing Address - Fax:
Practice Address - Street 1:1795 WILLISTON RD STE 330
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6487
Practice Address - Country:US
Practice Address - Phone:802-233-7420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-00011421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1015570Medicaid
VT000813701Medicare PIN