Provider Demographics
NPI:1972877611
Name:MOORE, JESSICA MARIE (LMP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MARIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5744 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:JOINT BASE LEWIS MCCHORD
Mailing Address - State:WA
Mailing Address - Zip Code:98433-1174
Mailing Address - Country:US
Mailing Address - Phone:253-973-8943
Mailing Address - Fax:
Practice Address - Street 1:5744 N 12TH ST
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98433-1174
Practice Address - Country:US
Practice Address - Phone:253-973-8943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60240933225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist