Provider Demographics
NPI:1679620488
Name:MOORE, JACQUELINE P (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:P
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:22777 W. ELEVEN MILE RD
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034
Mailing Address - Country:US
Mailing Address - Phone:248-358-0722
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:22777 W. ELEVEN MILE RD
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034
Practice Address - Country:US
Practice Address - Phone:248-358-0722
Practice Address - Fax:248-358-8658
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038170208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
JM038170OtherCOMMERCIAL-COMMERCIAL NUMBER
JM038170OtherCHAMPUS-CHAMPUS
JM038170OtherCOMMERCIAL-COMMERCIAL NUMBER