Provider Demographics
NPI:1174014450
Name:MOORE, JERICA (MA, ATC)
Entity Type:Individual
Prefix:
First Name:JERICA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 HIGHLAND AVE APT B
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6847
Mailing Address - Country:US
Mailing Address - Phone:863-381-8342
Mailing Address - Fax:
Practice Address - Street 1:1041 HAMILTION PLACE DR.
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-707-2509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20092255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer