Provider Demographics
NPI:1952655466
Name:MOORE, JACQUELINE ADELE (MT)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:ADELE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 SPINNAKER ST
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-8587
Mailing Address - Country:US
Mailing Address - Phone:224-628-2716
Mailing Address - Fax:
Practice Address - Street 1:1048 SPINNAKER ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-8587
Practice Address - Country:US
Practice Address - Phone:224-628-2716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227005797225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist