Provider Demographics
NPI:1003361411
Name:MORAN, JENNIE
Entity Type:Individual
Prefix:MS
First Name:JENNIE
Middle Name:
Last Name:MORAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 ATWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02919-3223
Mailing Address - Country:US
Mailing Address - Phone:401-785-2666
Mailing Address - Fax:401-785-2272
Practice Address - Street 1:1516 ATWOOD AVE
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919-3223
Practice Address - Country:US
Practice Address - Phone:401-785-2666
Practice Address - Fax:401-785-2272
Is Sole Proprietor?:No
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI56852Medicaid