Provider Demographics
NPI:1205128451
Name:MOORE, JEREMY CLINT (DO)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:CLINT
Last Name:MOORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5750A SOUTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36693-3316
Mailing Address - Country:US
Mailing Address - Phone:251-450-5916
Mailing Address - Fax:251-662-7297
Practice Address - Street 1:5800 SOUTHLAND DR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36693-3313
Practice Address - Country:US
Practice Address - Phone:251-450-2211
Practice Address - Fax:251-662-7297
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-06
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ALDO.13062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program