Provider Demographics
NPI:1306927447
Name:DAMBACH, JESSICA I (MA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:I
Last Name:DAMBACH
Suffix:
Gender:F
Credentials:MA
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 749
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05661-0749
Mailing Address - Country:US
Mailing Address - Phone:800-851-8603
Mailing Address - Fax:802-851-8313
Practice Address - Street 1:65 NORTHGATE PLAZA
Practice Address - Street 2:SUITE 11
Practice Address - City:MORRISVILLE
Practice Address - State:VT
Practice Address - Zip Code:05661-5900
Practice Address - Country:US
Practice Address - Phone:802-888-8320
Practice Address - Fax:802-888-8136
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680000596101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009127Medicaid