Provider Demographics
NPI:1578589263
Name:MOORE, JENNIFER REBECCA (AT, C, MED)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:REBECCA
Last Name:MOORE
Suffix:
Gender:F
Credentials:AT, C, MED
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 1:1190 S 18TH STREET EXT
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5378
Practice Address - Country:US
Practice Address - Phone:662-234-0424
Practice Address - Fax:662-234-0485
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT01152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer