Provider Demographics
NPI:1962536417
Name:MOORE, JEANETTE L (LCSW)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 S WALKER AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-7026
Mailing Address - Country:US
Mailing Address - Phone:405-634-4400
Mailing Address - Fax:405-632-1976
Practice Address - Street 1:105 SE 45TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73129-3201
Practice Address - Country:US
Practice Address - Phone:405-634-4400
Practice Address - Fax:405-632-1976
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical