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General NPI Number Information
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NPI Number | 1285151175
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Entity Type | Individual
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Provider Name | JESSICA VANDEVELDE MORENO LMFT
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Gender | Female
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Dates
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Enumeration Date | 08/23/2017
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Last Update Date | 02/13/2021
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Provider Practice Location Address
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Address Line | 601 VIRGINIA AVE N STE 1
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City | TIFTON
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State | GA
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Zip | 31794-4268
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Country | US
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Telephone | 229-233-7992
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1089
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City | OMEGA
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State | GA
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Zip | 31775-1089
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Country | US
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Telephone | 229-392-5273
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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 | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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