Provider Demographics
NPI:1942788104
Name:MOORE, JENNIFER HEINE (LVN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HEINE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1494
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-1494
Mailing Address - Country:US
Mailing Address - Phone:469-474-1777
Mailing Address - Fax:
Practice Address - Street 1:315 S GRAND SALINE ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:TX
Practice Address - Zip Code:75103-1355
Practice Address - Country:US
Practice Address - Phone:469-474-1777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA692539164X00000X
TX332189164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse