Provider Demographics
NPI:1386113421
Name:MOORE, STEPHANIE JADE (ADC)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:JADE
Last Name:MOORE
Suffix:
Gender:F
Credentials:ADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 VINE STREET
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72501-8638
Mailing Address - Country:US
Mailing Address - Phone:870-613-6624
Mailing Address - Fax:
Practice Address - Street 1:1104 VINE STREET
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-8638
Practice Address - Country:US
Practice Address - Phone:870-613-6624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1641101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)