Provider Demographics
NPI:1689222754
Name:MOORE, JACQUELINE BLAIR (LPC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:BLAIR
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MRS
Other - First Name:JACKIE
Other - Middle Name:BLAIR
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:14651 DALLAS PKWY STE 134
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-8904
Mailing Address - Country:US
Mailing Address - Phone:214-566-3698
Mailing Address - Fax:
Practice Address - Street 1:14651 DALLAS PKWY STE 134
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-8904
Practice Address - Country:US
Practice Address - Phone:214-566-3698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73741101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional