Basic Information
| Provider Information | |||||||||
| NPI: | 1487646303 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOFFATT | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LCSWR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 GREEN ST | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124014422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453313001 | ||||||||
| FaxNumber: | 8453354600 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 GREEN ST | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124014422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453313001 | ||||||||
| FaxNumber: | 8453354600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2005 | ||||||||
| LastUpdateDate: | 09/25/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | R074300-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.