Basic Information
Provider Information | |||||||||
NPI: | 1023181856 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOORE-DENCAUSE | ||||||||
FirstName: | JERRI | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MOORE | ||||||||
OtherFirstName: | JERRI | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LCSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1545 9TH ST SW | ||||||||
Address2: |   | ||||||||
City: | VERO BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 329624312 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7722578224 | ||||||||
FaxNumber: | 7722133157 | ||||||||
Practice Location | |||||||||
Address1: | 1400 27TH ST | ||||||||
Address2: |   | ||||||||
City: | VERO BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 329600303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7722578224 | ||||||||
FaxNumber: | 7722133157 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/17/2006 | ||||||||
LastUpdateDate: | 03/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | SW 12788 | FL | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | SW12788 | 01 | FL | STATE LICENSE | OTHER |