Provider Demographics
NPI:1518947340
Name:MOORE, JACQUETTA M (MFT)
Entity Type:Individual
Prefix:MS
First Name:JACQUETTA
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:MFT
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 77951
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92877-0131
Mailing Address - Country:US
Mailing Address - Phone:800-960-9915
Mailing Address - Fax:800-960-9915
Practice Address - Street 1:13193 CENTRAL AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710
Practice Address - Country:US
Practice Address - Phone:909-902-9111
Practice Address - Fax:909-902-9199
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT41345106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist