=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306270186
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACKIE DOROTHEA MOSER LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2013
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 708 S WOODBINE RD STE A
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64507-2098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-618-6259
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2536 N 26TH ST
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64506-1601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-617-6259
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2013030909
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------