Provider Demographics
NPI:1912273954
Name:MOLONEY, JESSICA (LMHC, NCC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MOLONEY
Suffix:
Gender:F
Credentials:LMHC, NCC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:TIETJEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 MONTAUK HWY STE 112
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4429
Mailing Address - Country:US
Mailing Address - Phone:631-321-7107
Mailing Address - Fax:
Practice Address - Street 1:400 MONTAUK HWY STE 112
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4429
Practice Address - Country:US
Practice Address - Phone:631-321-7107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-23
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004969101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health