Provider Demographics
NPI:1124551825
Name:MOYNIHAN, JENNIFER LAUREN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LAUREN
Last Name:MOYNIHAN
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 1:2855 S WHITNEY RD
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:IN
Mailing Address - Zip Code:47383-9735
Mailing Address - Country:US
Mailing Address - Phone:765-702-4900
Mailing Address - Fax:
Practice Address - Street 1:2000 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47306-3795
Practice Address - Country:US
Practice Address - Phone:765-285-5178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer