Provider Demographics
NPI:1649588963
Name:MOYLAN, JEAN LYDIA (LCPC)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:LYDIA
Last Name:MOYLAN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:LYDIA
Other - Last Name:WEGNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:T-9 FORT MISSOULA
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7202
Mailing Address - Country:US
Mailing Address - Phone:406-532-8400
Mailing Address - Fax:406-543-9316
Practice Address - Street 1:699 FARMHOUSE LN
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-9402
Practice Address - Country:US
Practice Address - Phone:406-522-7357
Practice Address - Fax:406-522-8361
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1495101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional