Provider Demographics
NPI:1073749768
Name:JEFF A. MOODY, PLLC
Entity Type:Organization
Organization Name:JEFF A. MOODY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:405-620-3508
Mailing Address - Street 1:3501 NW 63RD ST
Mailing Address - Street 2:SUITE 404
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-2237
Mailing Address - Country:US
Mailing Address - Phone:405-620-3508
Mailing Address - Fax:
Practice Address - Street 1:3501 NW 63RD ST
Practice Address - Street 2:SUITE 404
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-2237
Practice Address - Country:US
Practice Address - Phone:405-620-3508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty