MEDICARE: MR. ED JAY SCOTT L.C.S.W.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149.003173	IL

General Provider Information

NPI Number	:	1972851905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ED JAY SCOTT L.C.S.W.

Provider Business Mailing Address
First Line	:	201 E MORGAN ST
Second Line	:	P.O. BOX 1304
City	:	JACKSONVILLE
State	:	IL
Zip	:	62651
Country	:	US
Telephone Number	:	217-245-1655
Fax Number	:	217-245-4742

Provider Business Practice Location Address
First Line	:	201 E MORGAN ST
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-2587
Country	:	US
Telephone Number	:	217-245-1655
Fax Number	:	217-245-4742

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2012
Last Update Date	:	08/23/2012

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