Provider Demographics
NPI:1306533484
Name:MOORE, JACLYN MARY (LMSW, LSW)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARY
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMSW, LSW
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:MARY
Other - Last Name:KARMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2673 RUDDY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HIGH RIDGE
Mailing Address - State:MO
Mailing Address - Zip Code:63049-3709
Mailing Address - Country:US
Mailing Address - Phone:630-818-6899
Mailing Address - Fax:
Practice Address - Street 1:150 SAINT PETERS CENTRE BLVD STE B
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1653
Practice Address - Country:US
Practice Address - Phone:636-466-8497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.109222104100000X
MO2023013705104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker