Provider Demographics
NPI:1619919701
Name:MOAK, JAY THAMES (PHD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:THAMES
Last Name:MOAK
Suffix:
Gender:M
Credentials:PHD
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 768
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-0768
Mailing Address - Country:US
Mailing Address - Phone:601-249-2173
Mailing Address - Fax:601-249-4234
Practice Address - Street 1:1701 WHITE ST
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2711
Practice Address - Country:US
Practice Address - Phone:601-684-2173
Practice Address - Fax:601-249-4234
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS45-731103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical