Healthcare Provider Details

I. General information

NPI: 1205355344
Provider Name (Legal Business Name): JAMAR KIEL MOORE LGPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14440 CHERRY LANE CT STE 208
LAUREL MD
20707-4946
US

IV. Provider business mailing address

14440 CHERRY LANE CT STE 208
LAUREL MD
20707-4946
US

V. Phone/Fax

Practice location:
  • Phone: 301-604-1458
  • Fax: 301-604-1459
Mailing address:
  • Phone: 301-604-1458
  • Fax: 301-604-1459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLGP8021
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: