Provider Demographics
NPI:1962099572
Name:JENNIFER C MOORE MSW LCSW INC
Entity type:Organization
Organization Name:JENNIFER C MOORE MSW LCSW INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:C
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-240-8639
Mailing Address - Street 1:PO BOX 370763
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89137-0763
Mailing Address - Country:US
Mailing Address - Phone:702-240-8639
Mailing Address - Fax:702-240-6970
Practice Address - Street 1:660 S GREEN VALLEY PKWY STE 140-150
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-0430
Practice Address - Country:US
Practice Address - Phone:702-240-8639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-29
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100511332Medicaid