Healthcare Provider Details

I. General information

NPI: 1932273786
Provider Name (Legal Business Name): JACQUELINE MOYERMAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 HANNAHS MILL RD
THOMASTON GA
30286-2801
US

IV. Provider business mailing address

6326 CAPE COD DR
COLUMBUS GA
31904-2916
US

V. Phone/Fax

Practice location:
  • Phone: 706-646-4543
  • Fax:
Mailing address:
  • Phone: 706-570-1629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1583
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: