Provider Demographics
NPI:1861364069
Name:MOY, JACLYN
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:MOY
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 BRANDING AVE STE 345
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1401 BRANDING AVE STE 345
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1185
Practice Address - Country:US
Practice Address - Phone:331-254-4464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-18
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.022075101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health