Provider Demographics
NPI:1568018596
Name:MOYA, JACQUELINE IRENE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:IRENE
Last Name:MOYA
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 1:1845 ENDICOTT CIR
Mailing Address - Street 2:
Mailing Address - City:CARPENTERSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60110-2401
Mailing Address - Country:US
Mailing Address - Phone:847-338-4846
Mailing Address - Fax:
Practice Address - Street 1:2500 W HIGGINS RD STE 870
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-7266
Practice Address - Country:US
Practice Address - Phone:847-648-9204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician