Healthcare Provider Details

I. General information

NPI: 1689311862
Provider Name (Legal Business Name): JESSICA MOORE LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2022
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2631 HOUSLEY RD # 1298
ANNAPOLIS MD
21401-7030
US

IV. Provider business mailing address

3503 EMMA LN
PASADENA MD
21122-4176
US

V. Phone/Fax

Practice location:
  • Phone: 443-388-0160
  • Fax:
Mailing address:
  • Phone: 443-388-0160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLC15033
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC15033
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC15033
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: