Provider Demographics
NPI:1710254693
Name:MOORE, JEANNINE
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JEANNINE
Other - Middle Name:
Other - Last Name:SOTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1775 CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-1674
Mailing Address - Country:US
Mailing Address - Phone:562-599-8444
Mailing Address - Fax:
Practice Address - Street 1:1775 CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813
Practice Address - Country:US
Practice Address - Phone:562-599-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health