Provider Demographics
NPI:1699731778
Name:MOSES, JERRY RANDOLPH (LPC)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:RANDOLPH
Last Name:MOSES
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LRMC CMR 402
Mailing Address - Street 2:BOX 249
Mailing Address - City:LANDSTHUL
Mailing Address - State:APO AE
Mailing Address - Zip Code:09180
Mailing Address - Country:DE
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:LANDSTHUL REGIONAL CENTER
Practice Address - Street 2:
Practice Address - City:LANDSTHUL
Practice Address - State:APO AE
Practice Address - Zip Code:09180
Practice Address - Country:DE
Practice Address - Phone:486-8763
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2817101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)