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General NPI Number Information
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NPI Number | 1114738903
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Entity Type | Individual
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Provider Name | JAYLEN O'NEAL MOORE
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Gender | Male
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Dates
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Enumeration Date | 01/20/2025
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Last Update Date | 01/20/2025
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Provider Practice Location Address
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Address Line | 7272 E INDIAN SCHOOL RD
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City | SCOTTSDALE
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State | AZ
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Zip | 85251-3921
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Country | US
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Telephone | 480-389-6971
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Fax |
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Provider Business Mailing Address
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Address Line | 11287 N LUCKENBACH ST
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City | SURPRISE
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State | AZ
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Zip | 85388-3150
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Country | US
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Telephone | 951-850-9438
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LAC-23035
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License Number State | AZ
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