Provider Demographics
NPI:1891701355
Name:MOORE, JENNIFER (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 9TH ST SW
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32962-4312
Mailing Address - Country:US
Mailing Address - Phone:772-257-8224
Mailing Address - Fax:772-213-3157
Practice Address - Street 1:787 37TH ST STE 140
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-7305
Practice Address - Country:US
Practice Address - Phone:772-257-8224
Practice Address - Fax:772-213-3157
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90718207VG0400X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME90718OtherFL MEDICAL LICENSE
FL273111800Medicaid
FL12659YMedicare ID - Type UnspecifiedMEICARE PROVIDER NUMBER