Provider Demographics
NPI:1912324484
Name:MOORE, JESSICA (MA LLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6245 OPAL LN
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-7823
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1286 S LINDEN RD STE B
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3457
Practice Address - Country:US
Practice Address - Phone:810-407-7403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015852103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical