Provider Demographics
NPI:1659832319
Name:MOORE, JENNY LYN
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:LYN
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3405 KRISTIN LN
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-1801
Mailing Address - Country:US
Mailing Address - Phone:580-736-3388
Mailing Address - Fax:
Practice Address - Street 1:3011 N HWY 81
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-8923
Practice Address - Country:US
Practice Address - Phone:580-475-0014
Practice Address - Fax:580-475-0038
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator