Provider Demographics
NPI:1629519566
Name:MOODY, JAY B (PHLEBOTOMY TECHNICIA)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:B
Last Name:MOODY
Suffix:
Gender:M
Credentials:PHLEBOTOMY TECHNICIA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 CEDARBROOK RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-3046
Mailing Address - Country:US
Mailing Address - Phone:216-855-2658
Mailing Address - Fax:
Practice Address - Street 1:8314 VISTA AVE
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2068
Practice Address - Country:US
Practice Address - Phone:216-855-2658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-11
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH246RP1900X246RP1900X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy