Provider Demographics
NPI:1033382478
Name:MOORE, JILL DIMOND (MS, CCC)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:DIMOND
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 S WESTERN AVE
Mailing Address - Street 2:DEPT. 2004215
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-3413
Mailing Address - Country:US
Mailing Address - Phone:405-636-7131
Mailing Address - Fax:405-644-5476
Practice Address - Street 1:4401 S WESTERN AVE
Practice Address - Street 2:DEPT. 2004215
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3413
Practice Address - Country:US
Practice Address - Phone:405-636-7131
Practice Address - Fax:405-644-5476
Is Sole Proprietor?:No
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK239235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist