Provider Demographics
NPI:1245588987
Name:MOORE, JILLIAN LEIGH (PHD)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:LEIGH
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 1:359 COUNTRY CLUB DR APT 7
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-6690
Mailing Address - Country:US
Mailing Address - Phone:714-401-9239
Mailing Address - Fax:
Practice Address - Street 1:145 HODENCAMP RD STE 100
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360
Practice Address - Country:US
Practice Address - Phone:805-449-3545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29908103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist