Provider Demographics
NPI:1851614341
Name:MOEN, JEFFREY KENNETH (MS)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:KENNETH
Last Name:MOEN
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 BEN LORA LN
Mailing Address - Street 2:
Mailing Address - City:SAN BENITO
Mailing Address - State:TX
Mailing Address - Zip Code:78586-5104
Mailing Address - Country:US
Mailing Address - Phone:956-465-0518
Mailing Address - Fax:
Practice Address - Street 1:1014 BEN LORA LN
Practice Address - Street 2:
Practice Address - City:SAN BENITO
Practice Address - State:TX
Practice Address - Zip Code:78586-5104
Practice Address - Country:US
Practice Address - Phone:956-465-0518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16389101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional