1205065380 NPI number — JESSICA NICOLE MOODY LCPC, NCC, C.A.S.E.

Table of content: JESSICA NICOLE MOODY LCPC, NCC, C.A.S.E. (NPI 1205065380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205065380 NPI number — JESSICA NICOLE MOODY LCPC, NCC, C.A.S.E.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOODY
Provider First Name:
JESSICA
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC, NCC, C.A.S.E.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CORDOVA
Provider Other First Name:
JESSICA
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCPC, NCC, C.A.S.E.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205065380
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1212 COWPENS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOWSON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21286-1720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-809-1940
Provider Business Mailing Address Fax Number:
443-809-5898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1212 COWPENS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOWSON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21286-1720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-809-1940
Provider Business Practice Location Address Fax Number:
443-809-5898
Provider Enumeration Date:
07/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LC3100 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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