Provider Demographics
NPI:1548735632
Name:MOORE, JENNIFER (CAC II)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:CAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11706 W CHENANGO DR APT 3
Mailing Address - Street 2:
Mailing Address - City:MORRISON
Mailing Address - State:CO
Mailing Address - Zip Code:80465-2020
Mailing Address - Country:US
Mailing Address - Phone:720-270-9601
Mailing Address - Fax:
Practice Address - Street 1:1155 CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-3632
Practice Address - Country:US
Practice Address - Phone:303-602-5704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-04
Last Update Date:2021-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACB.0008407101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)