Provider Demographics
NPI:1730744251
Name:DOUGHTY-MOODY, JALISSA (LMFT)
Entity type:Individual
Prefix:MRS
First Name:JALISSA
Middle Name:
Last Name:DOUGHTY-MOODY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NW 82ND AVE STE 305
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-1835
Mailing Address - Country:US
Mailing Address - Phone:954-903-1676
Mailing Address - Fax:954-398-1338
Practice Address - Street 1:100 NW 82ND AVE STE 305
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-1835
Practice Address - Country:US
Practice Address - Phone:954-903-1676
Practice Address - Fax:954-398-1338
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2022-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT4050106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist