Provider Demographics
NPI:1093717746
Name:MOBERLEY, JORIE J (PHD, CPNP)
Entity Type:Individual
Prefix:
First Name:JORIE
Middle Name:J
Last Name:MOBERLEY
Suffix:
Gender:F
Credentials:PHD, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:9470 BROADWAY
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-5722
Practice Address - Country:US
Practice Address - Phone:219-661-3260
Practice Address - Fax:219-661-3770
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28142503A163WP0200X
IN71002006A363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200206460Medicaid
IN000000721668OtherANTHEM TRADITIONAL
IN200206460Medicaid
Q42164Medicare UPIN