Provider Demographics
NPI:1780978569
Name:MOFFETT, JAIME LEIGH (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JAIME
Middle Name:LEIGH
Last Name:MOFFETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6416 UNION STATION CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-4691
Mailing Address - Country:US
Mailing Address - Phone:516-524-2684
Mailing Address - Fax:
Practice Address - Street 1:5200 PARK RD
Practice Address - Street 2:SUITE 111, ROOM #2
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3650
Practice Address - Country:US
Practice Address - Phone:516-524-2684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0089091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical