Provider Demographics
NPI:1609444231
Name:MOSLEY, JENELLE ANDREA
Entity Type:Individual
Prefix:
First Name:JENELLE
Middle Name:ANDREA
Last Name:MOSLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENELLE
Other - Middle Name:ANDREA
Other - Last Name:EMORY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RP
Mailing Address - Street 1:11605 W DODGE RD STE 4
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-2566
Mailing Address - Country:US
Mailing Address - Phone:531-220-0976
Mailing Address - Fax:
Practice Address - Street 1:11605 W DODGE RD STE 4
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-2566
Practice Address - Country:US
Practice Address - Phone:531-220-0976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date: