Provider Demographics
NPI:1285682609
Name:MOODY, JACK HOLLAND (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:HOLLAND
Last Name:MOODY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 SIR THOMAS CT FL 1
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-4839
Mailing Address - Country:US
Mailing Address - Phone:717-988-0020
Mailing Address - Fax:717-703-5746
Practice Address - Street 1:805 SIR THOMAS CT
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109
Practice Address - Country:US
Practice Address - Phone:717-988-0020
Practice Address - Fax:717-703-5746
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040716L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001157470Medicaid
PA151071Medicare PIN
PA0011574700001Medicaid