Provider Demographics
NPI:1578533790
Name:MOORE, JEFFREY GLENN (ATC)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:GLENN
Last Name:MOORE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 HIGHWAY 334
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-9402
Mailing Address - Country:US
Mailing Address - Phone:662-281-8314
Mailing Address - Fax:
Practice Address - Street 1:ROOM 118 FIELDHOUSE
Practice Address - Street 2:ALL AMERICAN DRIVE
Practice Address - City:UNIVERSITY
Practice Address - State:MS
Practice Address - Zip Code:38677
Practice Address - Country:US
Practice Address - Phone:662-915-7536
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer