Provider Demographics
NPI:1356834949
Name:MORAN, JACKIE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:MORAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8405 W RS AVE
Mailing Address - Street 2:
Mailing Address - City:SCHOOLCRAFT
Mailing Address - State:MI
Mailing Address - Zip Code:49087-8432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:524 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5306
Practice Address - Country:US
Practice Address - Phone:269-324-1180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703099559164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse