Provider Demographics
NPI:1689816498
Name:MOSS, JACQUELINE ELAINE (LCSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ELAINE
Last Name:MOSS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4370 RED ROCK PT
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4081
Mailing Address - Country:US
Mailing Address - Phone:770-331-6592
Mailing Address - Fax:
Practice Address - Street 1:4411 SUWANEE DAM RD STE 450
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-8706
Practice Address - Country:US
Practice Address - Phone:770-283-8386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-26
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0044811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical