Provider Demographics
NPI:1679971865
Name:MOORE, JARED (PSYD)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4742 PINE ST
Mailing Address - Street 2:APT 402
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-1968
Mailing Address - Country:US
Mailing Address - Phone:201-310-6508
Mailing Address - Fax:
Practice Address - Street 1:4701 PINE ST
Practice Address - Street 2:APT. B13
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-1816
Practice Address - Country:US
Practice Address - Phone:201-310-6508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017735103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical