Provider Demographics
NPI:1063136026
Name:SCOTT, JESSICA (MED)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4803 REGENT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-3425
Mailing Address - Country:US
Mailing Address - Phone:610-637-6106
Mailing Address - Fax:
Practice Address - Street 1:123 S BROAD ST STE 1833
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19109-1026
Practice Address - Country:US
Practice Address - Phone:610-637-6106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7218276OtherTIMS