Provider Demographics
NPI:1306922612
Name:COFFIN, JONATHAN WEBSTER (LICSW, MACP, LADC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:WEBSTER
Last Name:COFFIN
Suffix:
Gender:F
Credentials:LICSW, MACP, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 FLYNN AVE
Mailing Address - Street 2:3-J
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5429
Mailing Address - Country:US
Mailing Address - Phone:802-658-0400
Mailing Address - Fax:802-660-3665
Practice Address - Street 1:300 FLYNN AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-5301
Practice Address - Country:US
Practice Address - Phone:802-488-6100
Practice Address - Fax:802-488-6901
Is Sole Proprietor?:No
Enumeration Date:2006-10-29
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000046101YA0400X
VT047-0000159103T00000X
VT089-00001921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007277Medicaid
VT1007277Medicaid