Provider Demographics
NPI:1679595797
Name:ROY, JACKIE M (NP)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:M
Last Name:ROY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:MINEAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 710
Mailing Address - Street 2:SPRINGFIELD MEDICAL CARE SYSTEMS
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-0710
Mailing Address - Country:US
Mailing Address - Phone:802-885-1166
Mailing Address - Fax:
Practice Address - Street 1:156 WALL ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-3528
Practice Address - Country:US
Practice Address - Phone:802-885-1166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0022863363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009172Medicaid
NH30342320Medicaid
VTP67649Medicare UPIN
VTNP3910Medicare PIN