Healthcare Provider Details

I. General information

NPI: 1003524729
Provider Name (Legal Business Name): JULIANA MOORE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2022
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2692 N DETTMAN RD
JACKSON MI
49201-8837
US

IV. Provider business mailing address

600 HARWOOD ST
JACKSON MI
49203-3016
US

V. Phone/Fax

Practice location:
  • Phone: 517-612-9902
  • Fax:
Mailing address:
  • Phone: 517-914-3935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401225725
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: