Provider Demographics
NPI:1295218667
Name:MOORE, JENNIFER ELAINE (RN BSN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELAINE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 VZ CR 2103
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:TX
Mailing Address - Zip Code:75103
Mailing Address - Country:US
Mailing Address - Phone:903-275-9570
Mailing Address - Fax:
Practice Address - Street 1:185 VZ CR 2103
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:TX
Practice Address - Zip Code:75103
Practice Address - Country:US
Practice Address - Phone:903-275-9570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX731517163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse