Provider Demographics
NPI:1669642989
Name:MOFFITT, JENNIFER (LPE-I)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MOFFITT
Suffix:
Gender:F
Credentials:LPE-I
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:EWBANK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPE-I
Mailing Address - Street 1:PO BOX 10681
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-0046
Mailing Address - Country:US
Mailing Address - Phone:479-790-6290
Mailing Address - Fax:479-439-9943
Practice Address - Street 1:26 E MEADOW ST STE 1
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-5357
Practice Address - Country:US
Practice Address - Phone:479-790-6290
Practice Address - Fax:479-439-9943
Is Sole Proprietor?:No
Enumeration Date:2008-03-03
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR08-10EI103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical