Provider Demographics
NPI:1679361034
Name:SCOTT, JACQUELYN R
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:R
Last Name:SCOTT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E 53RD AVE
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-1537
Mailing Address - Country:US
Mailing Address - Phone:219-484-1975
Mailing Address - Fax:
Practice Address - Street 1:8690 BROADWAY STE A
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7034
Practice Address - Country:US
Practice Address - Phone:219-750-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.112519104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker