Basic Information
Provider Information
NPI: 1003139494
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SCOTT
FirstName: JESSICA
MiddleName: L
NamePrefix:  
NameSuffix:  
Credential: BS, LSW, LADC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 403 4TH ST NW STE 300
Address2:  
City: BEMIDJI
State: MN
PostalCode: 566013196
CountryCode: US
TelephoneNumber: 2184445155
FaxNumber: 2183333921
Practice Location
Address1: 403 4TH ST NW STE 300
Address2:  
City: BEMIDJI
State: MN
PostalCode: 566013196
CountryCode: US
TelephoneNumber: 2184445155
FaxNumber: 2183333921
Other Information
ProviderEnumerationDate: 03/12/2010
LastUpdateDate: 03/12/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YA0400X302235MNY Behavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)

No ID Information.


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