Provider Demographics
NPI:1689025942
Name:MOODY, JIMMY SR
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:
Last Name:MOODY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JIMMY
Other - Middle Name:
Other - Last Name:MOODY
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:43 FERN LN
Mailing Address - Street 2:
Mailing Address - City:HAMMONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08037-9625
Mailing Address - Country:US
Mailing Address - Phone:609-567-5604
Mailing Address - Fax:
Practice Address - Street 1:43 FERN LN
Practice Address - Street 2:
Practice Address - City:HAMMONTON
Practice Address - State:NJ
Practice Address - Zip Code:08037-9625
Practice Address - Country:US
Practice Address - Phone:609-567-5604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health