Provider Demographics
NPI:1497269955
Name:MOODY, JESSICA MICHELLE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MICHELLE
Last Name:MOODY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1723 S SOLEIL CV
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1300
Mailing Address - Country:US
Mailing Address - Phone:801-870-8963
Mailing Address - Fax:
Practice Address - Street 1:3336 S PIONEER PKWY STE 201
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-2085
Practice Address - Country:US
Practice Address - Phone:801-313-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10378593-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical