Provider Demographics
NPI:1578384723
Name:MOORE, JENNIFER SUE (NCSP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUE
Last Name:MOORE
Suffix:
Gender:F
Credentials:NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 MEANDERING WAY
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-3687
Mailing Address - Country:US
Mailing Address - Phone:443-995-3630
Mailing Address - Fax:
Practice Address - Street 1:2644 RIVA RD
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7427
Practice Address - Country:US
Practice Address - Phone:410-222-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-21
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD151836P6D8Y3103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool