Provider Demographics
NPI:1154636611
Name:MOORE, SHANNON MONIQUE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MONIQUE
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 13563
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39236-3563
Mailing Address - Country:US
Mailing Address - Phone:769-524-4578
Mailing Address - Fax:769-524-4630
Practice Address - Street 1:1675 LAKELAND DR STE 304
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:769-524-4578
Practice Address - Fax:769-524-4630
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-09
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS55981103TC0700X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist