Provider Demographics
NPI:1578185773
Name:MOORE, JESSICA (MA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 WHITE PINE CT
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45255-4747
Mailing Address - Country:US
Mailing Address - Phone:901-833-3789
Mailing Address - Fax:
Practice Address - Street 1:1143 WHITE PINE CT
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45255-4747
Practice Address - Country:US
Practice Address - Phone:901-833-3789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6129101YP2500X
OH1901316101YP2500X
TN2657101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional