Healthcare Provider Details

I. General information

NPI: 1215669890
Provider Name (Legal Business Name): JENNIFER DARE MOEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W CIVIC CENTER DR # 700
SANTA ANA CA
92701-4515
US

IV. Provider business mailing address

401 W CIVIC CENTER DR
SANTA ANA CA
92701-4515
US

V. Phone/Fax

Practice location:
  • Phone: 714-480-6660
  • Fax:
Mailing address:
  • Phone: 714-480-4687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number125104
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: