Provider Demographics
NPI:1790332104
Name:MOORE, JENNIFER DAWN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
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 1:3154 JACKSON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CARNESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30521-4126
Mailing Address - Country:US
Mailing Address - Phone:770-546-9055
Mailing Address - Fax:
Practice Address - Street 1:3154 JACKSON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:CARNESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30521-4126
Practice Address - Country:US
Practice Address - Phone:770-861-4526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider