Provider Demographics
NPI:1972810091
Name:MOORE, JENNIFER L (LMHC #8858)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMHC #8858
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:291 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GROVELAND
Mailing Address - State:MA
Mailing Address - Zip Code:01834-1234
Mailing Address - Country:US
Mailing Address - Phone:978-712-8023
Mailing Address - Fax:978-388-8603
Practice Address - Street 1:291 MAIN ST
Practice Address - Street 2:
Practice Address - City:GROVELAND
Practice Address - State:MA
Practice Address - Zip Code:01834-1234
Practice Address - Country:US
Practice Address - Phone:978-712-8023
Practice Address - Fax:978-388-8603
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8858101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA8858OtherBOARD OF ALLIED MENTAL HEALTH