Provider Demographics
NPI:1396823084
Name:MOORE, JASON NICHOLAS (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:NICHOLAS
Last Name:MOORE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 BAYTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-7691
Mailing Address - Country:US
Mailing Address - Phone:214-529-2156
Mailing Address - Fax:
Practice Address - Street 1:4008 GATEWAY DR
Practice Address - Street 2:SUITE 180
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-7914
Practice Address - Country:US
Practice Address - Phone:817-358-0209
Practice Address - Fax:817-358-0219
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10451111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AP440OtherBLUE CROSS BLUE SHEILDS