MEDICARE: MS. JEANNE MARIE MOORE LCSW

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	L2996	OR
2	1041C0700X	Clinical Social Worker	LCS13412	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	77459698Z	OTHER		UNITED BEHAVIORAL HEALTH

General Provider Information

NPI Number	:	1700858412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JEANNE MARIE MOORE LCSW

Provider Business Mailing Address
First Line	:	2852 WILLAMETTE ST
Second Line	:	PMB #103
City	:	EUGENE
State	:	OR
Zip	:	97405-8200
Country	:	US
Telephone Number	:	541-684-9797
Fax Number	:	541-344-5599

Provider Business Practice Location Address
First Line	:	5 E 24TH AVE
Second Line	:	SUITE 4
City	:	EUGENE
State	:	OR
Zip	:	97405-2907
Country	:	US
Telephone Number	:	541-684-9797
Fax Number	:	541-344-5599

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

Provider Enumeration Date	:	02/06/2006
Last Update Date	:	07/08/2007

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