Provider Demographics
NPI:1619494135
Name:MOORE, JERI
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:
Last Name:MOORE
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 1:604 NE 2ND ST APT 220
Mailing Address - Street 2:
Mailing Address - City:DANIA
Mailing Address - State:FL
Mailing Address - Zip Code:33004-3309
Mailing Address - Country:US
Mailing Address - Phone:305-984-9661
Mailing Address - Fax:
Practice Address - Street 1:604 NE 2ND ST APT 220
Practice Address - Street 2:
Practice Address - City:DANIA
Practice Address - State:FL
Practice Address - Zip Code:33004-3309
Practice Address - Country:US
Practice Address - Phone:305-984-9661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH5195101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH5195OtherSTATE LICENSE