Provider Demographics
NPI:1508123159
Name:MOORE, JESSICA (ATC)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 BAY RD
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE
Mailing Address - State:VT
Mailing Address - Zip Code:05482-7754
Mailing Address - Country:US
Mailing Address - Phone:802-345-0263
Mailing Address - Fax:
Practice Address - Street 1:SAINT MICHAELS COLLEGE
Practice Address - Street 2:ONE WINOOSKI PARK, BOX 258
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05439-0001
Practice Address - Country:US
Practice Address - Phone:802-345-0263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT104.00000892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer