Provider Demographics
NPI:1649417957
Name:MOYER, JACQUELINE MAE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MAE
Last Name:MOYER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5013 STONE PARK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-9124
Mailing Address - Country:US
Mailing Address - Phone:706-610-7704
Mailing Address - Fax:
Practice Address - Street 1:7950 MARTIN LOOP
Practice Address - Street 2:#9200
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-5647
Practice Address - Country:US
Practice Address - Phone:706-615-7161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008888225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist