Provider Demographics
NPI:1083983514
Name:MORENO, JEFF RYAN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JEFF
Middle Name:RYAN
Last Name:MORENO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:923 16TH AVE S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-4731
Mailing Address - Country:US
Mailing Address - Phone:208-639-1514
Mailing Address - Fax:208-639-2301
Practice Address - Street 1:923 16TH AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4731
Practice Address - Country:US
Practice Address - Phone:208-639-1514
Practice Address - Fax:208-639-2301
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-29
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-318281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical