Provider Demographics
NPI:1063637502
Name:MOORE, JACQUETTA DEAN
Entity Type:Individual
Prefix:
First Name:JACQUETTA
Middle Name:DEAN
Last Name:MOORE
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 1:322 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-5811
Mailing Address - Country:US
Mailing Address - Phone:410-499-0938
Mailing Address - Fax:
Practice Address - Street 1:322 E 23RD ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5811
Practice Address - Country:US
Practice Address - Phone:410-499-0938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide