Provider Demographics
NPI:1962879668
Name:MOULTON, JAIMIE
Entity type:Individual
Prefix:MRS
First Name:JAIMIE
Middle Name:
Last Name:MOULTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1640
Mailing Address - Street 2:1450 MAIN ST.
Mailing Address - City:WEAVERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96093-1640
Mailing Address - Country:US
Mailing Address - Phone:530-623-1362
Mailing Address - Fax:530-623-1447
Practice Address - Street 1:1450 MAIN ST.
Practice Address - Street 2:
Practice Address - City:WEAVERVILLE
Practice Address - State:CA
Practice Address - Zip Code:96093-1640
Practice Address - Country:US
Practice Address - Phone:530-623-1362
Practice Address - Fax:530-623-1447
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health