Provider Demographics
NPI:1962658963
Name:MOORE, JODI-ANN CAMILLE (PA)
Entity Type:Individual
Prefix:
First Name:JODI-ANN
Middle Name:CAMILLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 MEDICAL DR NE STE E
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30121-8003
Mailing Address - Country:US
Mailing Address - Phone:470-227-1600
Mailing Address - Fax:470-227-1606
Practice Address - Street 1:9 MEDICAL DR NE STE E
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30121-8003
Practice Address - Country:US
Practice Address - Phone:470-227-1600
Practice Address - Fax:470-227-1606
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005365207N00000X, 363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I9704SSMedicare PIN