Provider Demographics
NPI:1639106420
Name:MOORE, JENNIFER RENEE (ATC, LMT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RENEE
Last Name:MOORE
Suffix:
Gender:F
Credentials:ATC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 E PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-3435
Mailing Address - Country:US
Mailing Address - Phone:217-243-3926
Mailing Address - Fax:
Practice Address - Street 1:209 E PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-3435
Practice Address - Country:US
Practice Address - Phone:217-243-3926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer