Provider Demographics
NPI:1134767312
Name:MOORE, JORDAN DAVID (MS, ATC, LAT, CSCS)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:DAVID
Last Name:MOORE
Suffix:
Gender:M
Credentials:MS, ATC, LAT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOSTON SPORTS INSTITUTE
Mailing Address - Street 2:900 WORCESTER ST
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482
Mailing Address - Country:US
Mailing Address - Phone:781-489-5088
Mailing Address - Fax:
Practice Address - Street 1:BOSTON SPORTS INSTITUTE
Practice Address - Street 2:900 WORCESTER ST
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482
Practice Address - Country:US
Practice Address - Phone:781-489-5088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA30062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer