Provider Demographics
NPI:1750632782
Name:MOORE, JACKIE RENA (BHRS)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:RENA
Last Name:MOORE
Suffix:
Gender:F
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5721 OAKWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:OK
Mailing Address - Zip Code:73084-8638
Mailing Address - Country:US
Mailing Address - Phone:405-413-8416
Mailing Address - Fax:
Practice Address - Street 1:5721 OAKWOOD ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:OK
Practice Address - Zip Code:73084-8638
Practice Address - Country:US
Practice Address - Phone:405-413-8416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation