Provider Demographics
NPI:1407490790
Name:SCOTT, JERRY MOORE
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:MOORE
Last Name:SCOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6184 OLD GLASGOW RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42164
Mailing Address - Country:US
Mailing Address - Phone:270-606-0909
Mailing Address - Fax:
Practice Address - Street 1:6184 OLD GLASGOW RD
Practice Address - Street 2:
Practice Address - City:SCOTTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42164
Practice Address - Country:US
Practice Address - Phone:270-606-0909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider