MEDICARE: JERRY R MOORE LPC, LICDC

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	101YP2500X	Professional Counselor	E.1901574-SUPV	OH

General Provider Information

NPI Number	:	1558845743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY R MOORE LPC, LICDC

Provider Business Mailing Address
First Line	:	16000 HUNTERS RUN
Second Line	:
City	:	MARYSVILLE
State	:	OH
Zip	:	43040-9659
Country	:	US
Telephone Number	:	614-582-1081
Fax Number	:

Provider Business Practice Location Address
First Line	:	16000 HUNTERS RUN
Second Line	:
City	:	MARYSVILLE
State	:	OH
Zip	:	43040-9659
Country	:	US
Telephone Number	:	614-582-1081
Fax Number	:

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

Provider Enumeration Date	:	09/24/2018
Last Update Date	:	04/08/2026

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