Provider Demographics
NPI:1891063236
Name:MOORE, JACK (OD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3700 MARTIN WAY E
Mailing Address - Street 2:#101
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5052
Mailing Address - Country:US
Mailing Address - Phone:360-456-2020
Mailing Address - Fax:360-438-2577
Practice Address - Street 1:3700 MARTIN WAY E
Practice Address - Street 2:#101
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5052
Practice Address - Country:US
Practice Address - Phone:360-456-2020
Practice Address - Fax:360-438-2577
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60240767152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist