Healthcare Provider Details

I. General information

NPI: 1962669713
Provider Name (Legal Business Name): JENNIFER LYNN MOORE LPCC-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 ODNR MOHICAN 51
PERRYSVILLE OH
44864-9407
US

IV. Provider business mailing address

1012 ODNR MOHICAN 51
PERRYSVILLE OH
44864-9407
US

V. Phone/Fax

Practice location:
  • Phone: 419-994-0300
  • Fax: 419-994-0300
Mailing address:
  • Phone: 419-994-0300
  • Fax: 419-994-0305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.0007958-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: