1699103069 NPI number — MR. JASON CARRIVEAU PMHNP-BC, RN, ATC

Table of content: MR. JASON CARRIVEAU PMHNP-BC, RN, ATC (NPI 1699103069)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699103069 NPI number — MR. JASON CARRIVEAU PMHNP-BC, RN, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARRIVEAU
Provider First Name:
JASON
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PMHNP-BC, RN, ATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699103069
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 38
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLISTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05495-0038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-498-8123
Provider Business Mailing Address Fax Number:
802-448-5637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28 PARK AVE STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLISTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05495-9701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-793-8636
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/23/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  101.0135812 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com