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General NPI Number Information
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NPI Number | 1295778389
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Entity Type | Individual
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Provider Name | JILL SHANNON GORDY-MOODY LCSW
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Gender | Female
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Dates
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Enumeration Date | 06/14/2006
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Last Update Date | 08/29/2013
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Provider Practice Location Address
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Address Line | 3350 LA JOLLA VILLAGE DR
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City | SAN DIEGO
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State | CA
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Zip | 92161-0002
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Country | US
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Telephone | 858-552-8585
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Fax |
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Provider Business Mailing Address
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Address Line | 154 DIANA ST
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City | ENCINITAS
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State | CA
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Zip | 92024-1401
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Country | US
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Telephone | 760-889-8933
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 0904005864
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License Number State | VA
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