Provider Demographics
NPI:1770863029
Name:MOORE, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
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 1:501 22ND ST
Mailing Address - Street 2:
Mailing Address - City:DUNBAR
Mailing Address - State:WV
Mailing Address - Zip Code:25064-1711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:285 CHURCH ST
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:WV
Practice Address - Zip Code:25043-9413
Practice Address - Country:US
Practice Address - Phone:304-587-4266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV50699163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool