Provider Demographics
NPI:1427923895
Name:MOORE, JACQUELYN JL (MHC-LP)
Entity type:Individual
Prefix:MISS
First Name:JACQUELYN
Middle Name:JL
Last Name:MOORE
Suffix:
Gender:F
Credentials:MHC-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 BOSWELL HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760
Mailing Address - Country:US
Mailing Address - Phone:607-203-1593
Mailing Address - Fax:
Practice Address - Street 1:950 BOSWELL HILL ROAD
Practice Address - Street 2:
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760
Practice Address - Country:US
Practice Address - Phone:607-203-1593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-07
Last Update Date:2025-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18-P127095101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health