Provider Demographics
NPI:1649750613
Name:MOORE, JESSE KINCAID
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:KINCAID
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4340 BORGEN BLVD
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98332-7000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4340 BORGEN BLVD
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98332-7000
Practice Address - Country:US
Practice Address - Phone:253-313-0704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-18
Last Update Date:2018-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist