Provider Demographics
NPI:1861228561
Name:MOSS, JENNY KATE
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:KATE
Last Name:MOSS
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 1:1121 S CHILTON AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2918
Mailing Address - Country:US
Mailing Address - Phone:318-957-0240
Mailing Address - Fax:
Practice Address - Street 1:3310 S BROADWAY AVE STE 100
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-7851
Practice Address - Country:US
Practice Address - Phone:903-781-1832
Practice Address - Fax:877-798-4959
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122843235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist