Provider Demographics
NPI:1033775952
Name:MOORE, JENNIFER LEA
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEA
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 CONDOR CT
Mailing Address - Street 2:
Mailing Address - City:NOBLE
Mailing Address - State:OK
Mailing Address - Zip Code:73068-8306
Mailing Address - Country:US
Mailing Address - Phone:405-650-2470
Mailing Address - Fax:
Practice Address - Street 1:2801 PARKLAWN DR
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-4211
Practice Address - Country:US
Practice Address - Phone:405-733-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist