Provider Demographics
NPI:1528473352
Name:MOELLER, JESSICA JANE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:JANE
Last Name:MOELLER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4045 NORMAN RD
Mailing Address - Street 2:
Mailing Address - City:BURTCHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48059-2116
Mailing Address - Country:US
Mailing Address - Phone:810-841-0512
Mailing Address - Fax:
Practice Address - Street 1:3111 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-8127
Practice Address - Country:US
Practice Address - Phone:810-966-7864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801095282104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker