Provider Demographics
NPI:1528370947
Name:MOORE, JERRY DON (LBP)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:DON
Last Name:MOORE
Suffix:
Gender:M
Credentials:LBP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 W CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-4057
Mailing Address - Country:US
Mailing Address - Phone:580-475-7162
Mailing Address - Fax:
Practice Address - Street 1:7 N 8TH ST
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-4601
Practice Address - Country:US
Practice Address - Phone:580-475-7162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0142101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health