Provider Demographics
NPI:1346834710
Name:MOORE, JENSEN (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENSEN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:JENSEN
Other - Middle Name:
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1927 JAKES RUN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:WV
Mailing Address - Zip Code:26570-8529
Mailing Address - Country:US
Mailing Address - Phone:304-680-9616
Mailing Address - Fax:
Practice Address - Street 1:215 MERIDETH ST
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-2561
Practice Address - Country:US
Practice Address - Phone:304-680-9616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-25
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-2280235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist