Provider Demographics
NPI:1841766292
Name:MOGA, JEANNINE LYNNE (LCSW)
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:LYNNE
Last Name:MOGA
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 1:107 ST ANDREWS
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23430-7169
Mailing Address - Country:US
Mailing Address - Phone:616-745-6148
Mailing Address - Fax:
Practice Address - Street 1:1736 S PARK CT STE 201
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-8922
Practice Address - Country:US
Practice Address - Phone:757-296-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040105011041C0700X
NC0079321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical