Provider Demographics
NPI:1134639636
Name:MOORE, JENNIFER A (PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 171341
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38187-1341
Mailing Address - Country:US
Mailing Address - Phone:256-656-5962
Mailing Address - Fax:
Practice Address - Street 1:310 S WALNUT BEND RD STE 2
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-7282
Practice Address - Country:US
Practice Address - Phone:256-656-5962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3353103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling