Healthcare Provider Details

I. General information

NPI: 1427510874
Provider Name (Legal Business Name): STEPHANIE MOSES LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 LAKELAND DR
JACKSON MS
39216-4719
US

IV. Provider business mailing address

1335 STANTON DR
JACKSON MS
39211-4223
US

V. Phone/Fax

Practice location:
  • Phone: 601-352-7784
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: