Provider Demographics
NPI:1568635514
Name:MOORE, JENNIFER A (LAC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 Z AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-3745
Mailing Address - Country:US
Mailing Address - Phone:541-910-2046
Mailing Address - Fax:
Practice Address - Street 1:1610 Z AVE
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-3745
Practice Address - Country:US
Practice Address - Phone:541-910-2046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01183171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist