Provider Demographics
NPI:1326537770
Name:MOSS, JENNIFER GRIFFIN
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:GRIFFIN
Last Name:MOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:GRIFFIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3209 WINDEMERE PL
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-2431
Mailing Address - Country:US
Mailing Address - Phone:440-479-2062
Mailing Address - Fax:
Practice Address - Street 1:110 NORTHWYND CIR STE B
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-3451
Practice Address - Country:US
Practice Address - Phone:434-515-1161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-01
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1237000017374700000X, 246ZA2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, MedicalGroup - Multi-Specialty
No374700000XNursing Service Related ProvidersTechnicianGroup - Multi-Specialty