Provider Demographics
NPI:1992156442
Name:CARPENTER, JESSA (ADC)
Entity type:Individual
Prefix:MS
First Name:JESSA
Middle Name:
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:ADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 PLEASANT ST
Mailing Address - Street 2:APT 2
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-1355
Mailing Address - Country:US
Mailing Address - Phone:802-274-7190
Mailing Address - Fax:
Practice Address - Street 1:117 PLEASANT ST
Practice Address - Street 2:APT 2
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-1355
Practice Address - Country:US
Practice Address - Phone:802-274-7190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT104440101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)