Provider Demographics
NPI:1932273786
Name:MOYERMAN, JACQUELINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:MOYERMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6326 CAPE COD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-2916
Mailing Address - Country:US
Mailing Address - Phone:706-570-1629
Mailing Address - Fax:
Practice Address - Street 1:210 HANNAHS MILL RD
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-2801
Practice Address - Country:US
Practice Address - Phone:706-646-4543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1583103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000461469CMedicaid
FLPY4912OtherPSYCHOLOGY LICENSE
GA1583OtherPSYCHOLOGY LICENSE
GA000461469CMedicaid
GA1583OtherPSYCHOLOGY LICENSE