Provider Demographics
NPI:1407184922
Name:MOORE, JEREMIAH ZANE (DPT)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:ZANE
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 CRESTBROOK RD UNIT 5
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6001
Mailing Address - Country:US
Mailing Address - Phone:503-341-4963
Mailing Address - Fax:
Practice Address - Street 1:8495 CRATER LAKE HWY
Practice Address - Street 2:U.S. DEPARTMENT OF VETERANS AFFAIRS - SORCC
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503
Practice Address - Country:US
Practice Address - Phone:541-826-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-20
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5649225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist