Provider Demographics
NPI:1629355870
Name:MOORE, JACKIE (MA)
Entity Type:Individual
Prefix:MR
First Name:JACKIE
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18530 MACK AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48236-3254
Mailing Address - Country:US
Mailing Address - Phone:313-673-9073
Mailing Address - Fax:313-884-8442
Practice Address - Street 1:18530 MACK AVE STE 101
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48236-3254
Practice Address - Country:US
Practice Address - Phone:313-673-9073
Practice Address - Fax:313-884-8442
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007537101YA0400X
MI6301005272103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling