Individual
MR. JACKIE MOORE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MA
Contact information
Practice address
18530 MACK AVE STE 101, GROSSE POINTE, MI 48236-3254
(313) 673-9073
(313) 884-8442
Mailing address
18530 MACK AVE STE 101, GROSSE POINTE, MI 48236-3254
(313) 673-9073
(313) 884-8442
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
6401007537
MI
103TC1900X
Counseling Psychologist
6301005272
MI
Other
Enumeration date
11/15/2011
Last updated
11/15/2011
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