Provider Demographics
NPI:1366271413
Name:SCOTT, JUANITA LYNN (PPSS)
Entity type:Individual
Prefix:MS
First Name:JUANITA
Middle Name:LYNN
Last Name:SCOTT
Suffix:
Gender:F
Credentials:PPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2908 MASSACHUSETTS WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-9721
Mailing Address - Country:US
Mailing Address - Phone:209-404-7028
Mailing Address - Fax:
Practice Address - Street 1:9950 WINDMILL PARK DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-4326
Practice Address - Country:US
Practice Address - Phone:209-404-7028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALEP4439103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool