Healthcare Provider Details

I. General information

NPI: 1306516349
Provider Name (Legal Business Name): JALYN MOFFET
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4215 31ST AVE S STE A
FARGO ND
58104-7743
US

IV. Provider business mailing address

4215 31ST AVE S STE A
FARGO ND
58104-7743
US

V. Phone/Fax

Practice location:
  • Phone: 701-478-0221
  • Fax:
Mailing address:
  • Phone: 701-478-0221
  • Fax: 701-478-0222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: