Provider Demographics
NPI:1790020766
Name:MOUZON, JESSICA NOELL
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NOELL
Last Name:MOUZON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 S NEW HOPE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4825
Mailing Address - Country:US
Mailing Address - Phone:704-208-1865
Mailing Address - Fax:704-208-1865
Practice Address - Street 1:609 S NEW HOPE RD STE 102
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4825
Practice Address - Country:US
Practice Address - Phone:704-208-1865
Practice Address - Fax:704-208-1865
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
NCA16006101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist