Provider Demographics
NPI:1831125855
Name:MOORE, JESSICA (MS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:HEUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:2330 CONCRETE RD
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:KY
Mailing Address - Zip Code:40311-9700
Mailing Address - Country:US
Mailing Address - Phone:859-289-7126
Mailing Address - Fax:
Practice Address - Street 1:2330 CONCRETE RD
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:KY
Practice Address - Zip Code:40311-9700
Practice Address - Country:US
Practice Address - Phone:859-289-7126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
201132103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid
KY184607OtherMEDICARE GROUP NUMBER
KY1790731081Medicaid