Provider Demographics
NPI:1619674751
Name:MOORE, JACQUELINE COLLEEN (DPT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:COLLEEN
Last Name:MOORE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 881360
Mailing Address - Street 2:
Mailing Address - City:STEILACOOM
Mailing Address - State:WA
Mailing Address - Zip Code:98388-0410
Mailing Address - Country:US
Mailing Address - Phone:253-722-5511
Mailing Address - Fax:
Practice Address - Street 1:8524 STEILACOOM BLVD SW STE 201B
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98498-4772
Practice Address - Country:US
Practice Address - Phone:253-722-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT61276823225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist