Provider Demographics
NPI:1679460810
Name:MOORE, JORDAN BREANNE
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:BREANNE
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 1:591 TURIN WAY APT 26101
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1583
Mailing Address - Country:US
Mailing Address - Phone:760-881-5773
Mailing Address - Fax:
Practice Address - Street 1:495 N SHILLING AVE
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-2336
Practice Address - Country:US
Practice Address - Phone:435-744-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-20
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator