Provider Demographics
NPI:1831713858
Name:FETTIG, JAMIE (LMHC)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:FETTIG
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1665 SCOTT RD
Mailing Address - Street 2:
Mailing Address - City:ST JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-9209
Mailing Address - Country:US
Mailing Address - Phone:484-951-8754
Mailing Address - Fax:
Practice Address - Street 1:1665 SCOTT RD
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-9209
Practice Address - Country:US
Practice Address - Phone:484-951-8754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH14295101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health