Provider Demographics
NPI:1093923864
Name:MOORE, JASON ELLIS (OTR)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:ELLIS
Last Name:MOORE
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 EDMAR AVE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-7603
Mailing Address - Country:US
Mailing Address - Phone:740-373-0761
Mailing Address - Fax:
Practice Address - Street 1:35 EDMAR AVE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-7603
Practice Address - Country:US
Practice Address - Phone:740-373-0761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT.006728225X00000X
WV1318225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist