Provider Demographics
NPI:1922580737
Name:SCOTT, JACQUELINE RENEE (LADC, MATS, CCJP,)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RENEE
Last Name:SCOTT
Suffix:
Gender:F
Credentials:LADC, MATS, CCJP,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:566 WILMOT AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06607-1107
Mailing Address - Country:US
Mailing Address - Phone:203-540-9524
Mailing Address - Fax:
Practice Address - Street 1:566 WILMOT AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06607-1107
Practice Address - Country:US
Practice Address - Phone:203-540-9524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)