Provider Demographics
NPI:1326474156
Name:MOULTON, JAMAICA SANTOS (LPC 1490)
Entity Type:Individual
Prefix:
First Name:JAMAICA
Middle Name:SANTOS
Last Name:MOULTON
Suffix:
Gender:F
Credentials:LPC 1490
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 2772
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-2772
Mailing Address - Country:US
Mailing Address - Phone:307-899-2492
Mailing Address - Fax:307-578-8130
Practice Address - Street 1:337 ROBERT ST
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-9268
Practice Address - Country:US
Practice Address - Phone:307-899-2492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-781171M00000X, 172V00000X
WYWY-1490101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker