Provider Demographics
NPI:1659459618
Name:MOORE, JACQUELINE (PT DSC OCS ATC CSCS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT DSC OCS ATC CSCS
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:COLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT DSC OCS ATC CSCS
Mailing Address - Street 1:34800 BOB WILSON DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-1098
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-532-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33853225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist