Provider Demographics
NPI:1417628280
Name:MOULIERT, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MOULIERT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 ROSELLE AVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-6698
Mailing Address - Country:US
Mailing Address - Phone:609-432-3081
Mailing Address - Fax:
Practice Address - Street 1:1817 OLDE HOMESTEAD LN
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-6751
Practice Address - Country:US
Practice Address - Phone:223-275-3158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
PAPC017036101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor