Provider Demographics
NPI:1518779453
Name:PROULX, JESSICA (RMFTI)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PROULX
Suffix:
Gender:F
Credentials:RMFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2241 ROBERT D RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-9786
Mailing Address - Country:US
Mailing Address - Phone:386-785-6013
Mailing Address - Fax:
Practice Address - Street 1:365 WEKIVA SPRINGS RD STE 231
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-3690
Practice Address - Country:US
Practice Address - Phone:386-785-6013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4217106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist