Provider Demographics
NPI:1104189752
Name:MORA, JENNIFER LYN (SPED, MS)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYN
Last Name:MORA
Suffix:
Gender:F
Credentials:SPED, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 E BROADWAY APT 1
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-4729
Mailing Address - Country:US
Mailing Address - Phone:516-456-2233
Mailing Address - Fax:
Practice Address - Street 1:624 E BROADWAY APT 1
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-4729
Practice Address - Country:US
Practice Address - Phone:516-456-2233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY479959101174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist