Provider Demographics
NPI:1437319407
Name:MOORE, JACQUELINE MCCLELLAN (DO)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MCCLELLAN
Last Name:MOORE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10850 E TRAVERSE HWY
Mailing Address - Street 2:STE 4400
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-1364
Mailing Address - Country:US
Mailing Address - Phone:231-346-6800
Mailing Address - Fax:231-346-6096
Practice Address - Street 1:1105 SIXTH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2349
Practice Address - Country:US
Practice Address - Phone:231-935-5800
Practice Address - Fax:231-935-5885
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017571207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine