MEDICARE: MRS. JENNIFER STALLER MOON LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	016935	GA

General Provider Information

NPI Number	:	1023942174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER STALLER MOON LPC

Provider Business Mailing Address
First Line	:	2445 CHURCHILL DOWNS
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30041-8269
Country	:	US
Telephone Number	:	470-353-5596
Fax Number	:

Provider Business Practice Location Address
First Line	:	2445 CHURCHILL DOWNS
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30041-8269
Country	:	US
Telephone Number	:	470-353-5596
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2026
Last Update Date	:	06/11/2026

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