Provider Demographics
NPI:1962669713
Name:MOORE, JENNIFER LYNN (LPCC-S)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 ODNR MOHICAN 51
Mailing Address - Street 2:
Mailing Address - City:PERRYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44864-9407
Mailing Address - Country:US
Mailing Address - Phone:419-994-0300
Mailing Address - Fax:419-994-0305
Practice Address - Street 1:1012 ODNR MOHICAN 51
Practice Address - Street 2:
Practice Address - City:PERRYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44864-9407
Practice Address - Country:US
Practice Address - Phone:419-994-0300
Practice Address - Fax:419-994-0300
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0007958-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0260387Medicaid