Healthcare Provider Details

I. General information

NPI: 1114738903
Provider Name (Legal Business Name): JAYLEN O'NEAL MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2025
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7272 E INDIAN SCHOOL RD
SCOTTSDALE AZ
85251-3921
US

IV. Provider business mailing address

11287 N LUCKENBACH ST
SURPRISE AZ
85388-3150
US

V. Phone/Fax

Practice location:
  • Phone: 480-389-6971
  • Fax:
Mailing address:
  • Phone: 951-850-9438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLAC-23035
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: