Provider Demographics
NPI:1205065380
Name:MOODY, JESSICA NICOLE (LCPC, NCC, CASE)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:MOODY
Suffix:
Gender:F
Credentials:LCPC, NCC, CASE
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:NICOLE
Other - Last Name:CORDOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC, NCC, CASE
Mailing Address - Street 1:1212 COWPENS AVE
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-1720
Mailing Address - Country:US
Mailing Address - Phone:443-809-1940
Mailing Address - Fax:443-809-5898
Practice Address - Street 1:1212 COWPENS AVE
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-1720
Practice Address - Country:US
Practice Address - Phone:443-809-1940
Practice Address - Fax:443-809-5898
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3100101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional