Provider Demographics
NPI:1285151175
Name:VANDEVELDE MORENO, JESSICA (LMFT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:VANDEVELDE MORENO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1089
Mailing Address - Street 2:
Mailing Address - City:OMEGA
Mailing Address - State:GA
Mailing Address - Zip Code:31775-1089
Mailing Address - Country:US
Mailing Address - Phone:229-392-5273
Mailing Address - Fax:
Practice Address - Street 1:601 VIRGINIA AVE N STE 1
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-4268
Practice Address - Country:US
Practice Address - Phone:229-233-7992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist