Provider Demographics
NPI:1619677622
Name:MOORE, JACEY MATTISON (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:JACEY
Middle Name:MATTISON
Last Name:MOORE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 BEREA RD
Mailing Address - Street 2:
Mailing Address - City:ELDRIDGE
Mailing Address - State:AL
Mailing Address - Zip Code:35554-4200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:238 BEREA RD
Practice Address - Street 2:
Practice Address - City:ELDRIDGE
Practice Address - State:AL
Practice Address - Zip Code:35554-4200
Practice Address - Country:US
Practice Address - Phone:205-270-9025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-08
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6104225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist