Provider Demographics
NPI:1164819603
Name:JENNIFER M MOSS
Entity Type:Organization
Organization Name:JENNIFER M MOSS
Other - Org Name:CONCHO VALLEY OB-GYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:325-944-9999
Mailing Address - Street 1:3019 GREEN MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-6975
Mailing Address - Country:US
Mailing Address - Phone:325-944-9999
Mailing Address - Fax:325-944-9996
Practice Address - Street 1:3019 GREEN MEADOW DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-6975
Practice Address - Country:US
Practice Address - Phone:325-944-9999
Practice Address - Fax:325-944-9996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-22
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7835261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1508019993OtherNPI