Provider Demographics
NPI:1487646303
Name:MOFFATT, JEAN L (LCSWR)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:L
Last Name:MOFFATT
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-4422
Mailing Address - Country:US
Mailing Address - Phone:845-331-3001
Mailing Address - Fax:845-335-4600
Practice Address - Street 1:124 GREEN ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-4422
Practice Address - Country:US
Practice Address - Phone:845-331-3001
Practice Address - Fax:845-335-4600
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR074300-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA3000036005Medicare PIN