Provider Demographics
NPI:1093602906
Name:JACQUELINE MOORE PLLC
Entity type:Organization
Organization Name:JACQUELINE MOORE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, ARNP, PMHNP-BC
Authorized Official - Phone:360-322-4711
Mailing Address - Street 1:701 NE 136TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-6937
Mailing Address - Country:US
Mailing Address - Phone:360-322-4711
Mailing Address - Fax:360-583-6404
Practice Address - Street 1:701 NE 136TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6937
Practice Address - Country:US
Practice Address - Phone:360-322-4711
Practice Address - Fax:360-583-6404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty