Provider Demographics
NPI:1558845743
Name:MOORE, JERRY R (LPC, LICDC)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:R
Last Name:MOORE
Suffix:
Gender:M
Credentials:LPC, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16000 HUNTERS RUN
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-9659
Mailing Address - Country:US
Mailing Address - Phone:614-582-1081
Mailing Address - Fax:
Practice Address - Street 1:16000 HUNTERS RUN
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-9659
Practice Address - Country:US
Practice Address - Phone:614-582-1081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1700627101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor