Provider Demographics
NPI:1851357438
Name:MOSS, JACQUE D (FLP)
Entity Type:Individual
Prefix:
First Name:JACQUE
Middle Name:D
Last Name:MOSS
Suffix:
Gender:F
Credentials:FLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2310 RABY RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-7761
Practice Address - Country:US
Practice Address - Phone:235-176-7697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005067103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C36233006Medicare ID - Type UnspecifiedMEDICARE