Provider Demographics
NPI:1255113684
Name:MOORE, JANE (LCSW)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 145
Mailing Address - Street 2:
Mailing Address - City:MERRIFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22116-0145
Mailing Address - Country:US
Mailing Address - Phone:434-602-1280
Mailing Address - Fax:
Practice Address - Street 1:8230 OLD COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3853
Practice Address - Country:US
Practice Address - Phone:434-602-1280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040159581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical