Provider Demographics
NPI:1043207194
Name:MOORE, JESSICA DYAN (OD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DYAN
Last Name:MOORE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:DYAN
Other - Last Name:DAMROW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 75
Mailing Address - Street 2:
Mailing Address - City:SUTTON
Mailing Address - State:NE
Mailing Address - Zip Code:68979-0075
Mailing Address - Country:US
Mailing Address - Phone:402-366-6966
Mailing Address - Fax:
Practice Address - Street 1:210 N SAUNDERS AVE
Practice Address - Street 2:
Practice Address - City:SUTTON
Practice Address - State:NE
Practice Address - Zip Code:68979-2511
Practice Address - Country:US
Practice Address - Phone:402-366-6966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1183152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE22-00509OtherUNITED HEALTH CARE
NE410048038OtherRAILROAD MEDICARE
NE36383OtherBLUE CROSS BLUE SHIELD
NE0183380002OtherDMERC
NE36383OtherBLUE CROSS BLUE SHIELD
NEU90544Medicare UPIN