Provider Demographics
NPI:1972189447
Name:SIMON, JEREMY SCOTT (MS, LCDC, LPC-I)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:SCOTT
Last Name:SIMON
Suffix:
Gender:M
Credentials:MS, LCDC, LPC-I
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 1503
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-1503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:756 PURPLE SAGE RD
Practice Address - Street 2:
Practice Address - City:BANDERA
Practice Address - State:TX
Practice Address - Zip Code:78003
Practice Address - Country:US
Practice Address - Phone:844-448-2567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80898101YM0800X
TX14709101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health