Provider Demographics
NPI:1699409078
Name:MOSS, JEREMEY
Entity Type:Individual
Prefix:
First Name:JEREMEY
Middle Name:
Last Name:MOSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 M L KING DR
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3058
Mailing Address - Country:US
Mailing Address - Phone:618-533-1391
Mailing Address - Fax:
Practice Address - Street 1:904 M L KING DR
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3058
Practice Address - Country:US
Practice Address - Phone:618-533-1391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370915481007Medicaid