Provider Demographics
NPI:1760910699
Name:MOORE, JENNIFER JANE (GC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JANE
Last Name:MOORE
Suffix:
Gender:F
Credentials:GC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-1647
Mailing Address - Fax:
Practice Address - Street 1:7120 CLEARVISTA DR STE 5900
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1714
Practice Address - Country:US
Practice Address - Phone:317-621-5395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN74000181A170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300008014Medicaid
IN74000181AOtherINDIANA GENETIC COUNSELOR LICENSE
KSK02-66-8390OtherDRIVERS LICENSE