Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | 7967 | NC |
NPI | 1003254293 |
---|---|
Provider Name | Jessica Theresa Moore-Tyson |
First Address | Jacksonville, NC 28546-7364 |
Second Address | Jacksonville, NC 28546-7364 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2013 |
Last Update Date | 10/06/2013 |