Provider Demographics
NPI:1316452824
Name:BROUILLETTE, JERRI (LADC)
Entity type:Individual
Prefix:
First Name:JERRI
Middle Name:
Last Name:BROUILLETTE
Suffix:
Gender:F
Credentials:LADC
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:802-888-6051
Mailing Address - Fax:
Practice Address - Street 1:65 NORTHGATE PLZ STE 11
Practice Address - Street 2:
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:
Is Sole Proprietor?:No
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT151.0125298101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT151.0125298OtherSTATE LICENSE