Provider Demographics
NPI:1629684907
Name:MOORE, JACLYN VAUGHN (RD)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:VAUGHN
Last Name:MOORE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4804 DEER MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-6717
Mailing Address - Country:US
Mailing Address - Phone:502-645-9066
Mailing Address - Fax:
Practice Address - Street 1:234 E GRAY ST STE 164
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1903
Practice Address - Country:US
Practice Address - Phone:502-629-2405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY163224133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered