1700858412 NPI number — MS. JEANNE MARIE MOORE LCSW

Table of content: MS. JEANNE MARIE MOORE LCSW (NPI 1700858412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700858412 NPI number — MS. JEANNE MARIE MOORE LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
JEANNE MARIE
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700858412
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2852 WILLAMETTE ST
Provider Second Line Business Mailing Address:
PMB #103
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97405-8200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-684-9797
Provider Business Mailing Address Fax Number:
541-344-5599

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 E 24TH AVE
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97405-2907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-684-9797
Provider Business Practice Location Address Fax Number:
541-344-5599
Provider Enumeration Date:
02/06/2006

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: 1041C0700X , with the licence number:  L2996 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: LCS13412 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 77459698Z . This is a "UNITED BEHAVIORAL HEALTH" identifier . This identifiers is of the category "OTHER".




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