Provider Demographics
NPI:1780446237
Name:MOSS, JENNIFER RAE (AMFT, APCC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:MOSS
Suffix:
Gender:F
Credentials:AMFT, APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 FORD PL APT 3
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1706
Mailing Address - Country:US
Mailing Address - Phone:804-513-5138
Mailing Address - Fax:
Practice Address - Street 1:1211 CENTER COURT DR STE 106
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-3693
Practice Address - Country:US
Practice Address - Phone:626-833-8034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA15213101YM0800X
CAA142949106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health