1306533484 NPI number — JACLYN MARY MOORE LMSW, LSW

Table of content: JACLYN MARY MOORE LMSW, LSW (NPI 1306533484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306533484 NPI number — JACLYN MARY MOORE LMSW, LSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
JACLYN
Provider Middle Name:
MARY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW, LSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KARMAN
Provider Other First Name:
JACLYN
Provider Other Middle Name:
MARY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306533484
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2673 RUDDY RIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIGH RIDGE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63049-3709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-818-6899
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 SAINT PETERS CENTRE BLVD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PETERS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63376-1653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-466-8497
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/19/2023

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: 104100000X , with the licence number:  150.109222 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: 2023013705 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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