Provider Demographics
NPI:1639797830
Name:EWING, JESSE
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:EWING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5992 WESTGATE DR APT 202
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-7036
Mailing Address - Country:US
Mailing Address - Phone:256-426-1830
Mailing Address - Fax:
Practice Address - Street 1:5992 WESTGATE DR APT 202
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-7036
Practice Address - Country:US
Practice Address - Phone:256-426-1830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17154101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health