Healthcare Provider Details

I. General information

NPI: 1831025261
Provider Name (Legal Business Name): JENNIFER L MOORE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 RIVERSIDE PKWY
FREDERICKSBURG VA
22406-1094
US

IV. Provider business mailing address

5222 YELLOW BIRCH DR
FREDERICKSBURG VA
22407-9336
US

V. Phone/Fax

Practice location:
  • Phone: 540-300-7933
  • Fax:
Mailing address:
  • Phone: 256-223-2882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904020554
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: