Provider Demographics
NPI:1679883920
Name:MOORE, JEFFREY JAY (MA, LLPC)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:JAY
Last Name:MOORE
Suffix:
Gender:M
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 MEADOWFIELD DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-4805
Mailing Address - Country:US
Mailing Address - Phone:616-551-2328
Mailing Address - Fax:
Practice Address - Street 1:901 EASTERN AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1201
Practice Address - Country:US
Practice Address - Phone:616-224-7617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011917101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional