Provider Demographics
NPI:1861080533
Name:MOORE, JASMYN LYNN
Entity type:Individual
Prefix:
First Name:JASMYN
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JASMYN
Other - Middle Name:LYNN
Other - Last Name:BOBBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8 RASHEEDA CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-3846
Mailing Address - Country:US
Mailing Address - Phone:336-383-2613
Mailing Address - Fax:
Practice Address - Street 1:5 CORPORATE CENTER CT UNIT 200-A
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-2033
Practice Address - Country:US
Practice Address - Phone:336-257-0404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12252A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist