Healthcare Provider Details

I. General information

NPI: 1649232109
Provider Name (Legal Business Name): JIMMY MOORE MSW,LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 ROANOKE BLVD
SALEM VA
24153-6404
US

IV. Provider business mailing address

172 FOREST DR
SALEM VA
24153-6860
US

V. Phone/Fax

Practice location:
  • Phone: 540-983-1018
  • Fax: 540-224-1932
Mailing address:
  • Phone: 540-389-1219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904002321
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: