Provider Demographics
NPI:1841599974
Name:SCOTT, JESSIE IVELYN (MA LMHC)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:IVELYN
Last Name:SCOTT
Suffix:
Gender:F
Credentials:MA LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 LOCHMOND DR
Mailing Address - Street 2:
Mailing Address - City:FERN PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32730-2636
Mailing Address - Country:US
Mailing Address - Phone:407-486-0239
Mailing Address - Fax:
Practice Address - Street 1:165 SABAL PALM DR STE 151
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-2593
Practice Address - Country:US
Practice Address - Phone:407-486-0239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-15
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MH-15114101YA0400X
FLMH-15114101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021815800Medicaid